PharmCAS 2017-2018 Cycle Macintyre, megrady444 … PharmCAS...PharmCAS 2017-2018 Cycle Macintyre, megrady444 Applicant ID8949477491 Application StatusVerified Watertown University

BIOGRAPHIC INFORMABIOGRAPHIC INFORMATIONTION

PRPROFILEOFILE

Title:Title: Mr

First Name:First Name: megrady444

Middle Name:Middle Name: Ali

Last Name:Last Name: Macintyre

Suffix:Suffix: Junior

Gender or SeGender or Sex:x: MALE

Materials Under Another Name:Materials Under Another Name: Yes

Nickname:Nickname: Macintosh

Alternate First Name:Alternate First Name: Carmelo

Alternate Middle Name:Alternate Middle Name: blackhole

Alternate Last Name:Alternate Last Name: Macintyre

BIRBIRTH INFORMATH INFORMATIONTION

Date of Birth:Date of Birth: 07-20-1998

City:City: Mauriceville

County:County: N/A

State:State: International

Country:Country: Egypt

CONTCONTAACT INFORMACT INFORMATIONTION

Address TAddress Type:ype: Current

Address:Address: 123 West St111Mauriceville, California 00010

County:County: Inyo County

Country:Country: United States

VValid Until Date:alid Until Date: 07-20-2020

Phone:Phone: +16175551212 TType:ype: Cell

+16172221515 TType:ype: Home

Email:Email: [email protected] TType:ype: School

Address TAddress Type:ype: Permanent

Address:Address: 123 Any St111Justinville, Maine 12212

County:County: Oxford County

Country:Country: United States

CITIZENSHIP STCITIZENSHIP STAATUS AND RESIDENCY INFORMATUS AND RESIDENCY INFORMATIONTION

CITIZENSHIP STCITIZENSHIP STAATUSTUS

Citizenship Status:Citizenship Status: Permanent U.S. Resident

Country of Citizenship:Country of Citizenship: Antigua and Barbuda

Other Citizenship:Other Citizenship: Nepal

LLength of staength of stay in US:y in US: 3-5 years

State of Residence:State of Residence: Arkansas

County of Residence:County of Residence: Bradley County

LLength of Residence:ength of Residence: 3-5 years

VISA STVISA STAATUSTUS

Visa TVisa Type:ype: Visa Waiver WB

Visa Number:Visa Number: a1d5133

Issuing Authority:Issuing Authority: Thomas Brady

Issued in City:Issued in City: Uganda

Issued in Country:Issued in Country: Denmark

VValid Dates:alid Dates: 01-01-2011 / 04-20-2020

Visa Sponsor:Visa Sponsor: Robert Gronkowski

PharmCAS 2017-2018 CyPharmCAS 2017-2018 Cyclecle Macintyre, megrMacintyre, megrady444ady444Applicant ID 89494774918949477491 Application Status VVerifiederified

WWatertown Univatertown Universityersity

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BIOGRAPHIC INFORMABIOGRAPHIC INFORMATIONTION CONTINUEDCONTINUED

RARACE/ETHNICITYCE/ETHNICITY

Do yDo you consider you consider yourself to be of Hispanic/Latino Origin?ourself to be of Hispanic/Latino Origin?

Answer:Answer: Yes

Cuban: a

Mexican: a

Puerto Rican: a

South American: a

Other: Spanish

African American:African American: Yes

Asian:Asian: Yes

Asian Indian: a

Cambodian: a

Chinese: a

Filipino: a

Japanese: a

Korean: a

Malaysian: a

Pakistani: a

Vietnamese: a

Other: Asian

PPacific Islander:acific Islander: Yes

Guamanian: a

Hawaiian: a

Samoan: a

Other: Islander

American Indian:American Indian: Yes

Tribe Name: Indian

White:White: Yes

OOTHER INFORMATHER INFORMATIONTION

NativNative Language:e Language: Afrihili

Additional Language:Additional Language: Edo Proficiency LProficiency Leevvel:el: Beginner

Additional Language:Additional Language: Inari Sami Proficiency LProficiency Leevvel:el: Advanced

Additional Language:Additional Language: Nyamwezi Proficiency LProficiency Leevvel:el: Intermediate

Military Status:Military Status: Member of Reserve or National Guard

HaHavve ye you eou evver been coner been convicted of a Fvicted of a Felonelony?y?

Answer:Answer: Yes

Explanation:Explanation: My summer training at TIFR has given me the experience of working in an organization oriented towards research.In the course of the two months I spent there, my interaction with the Theoretical Computer Science group hastaught me a lot of things and also whets my appetite for more knowledge. I realize how important it is, as aresearcher, to interact with other people working in the same field, and at the same time, am able to workindividually.My summer training at TIFR has given me the expe.

HaHavve ye you eou evver had aner had any certification, registry certification, registration, license or clinical privileges reation, license or clinical privileges revvokoked, suspended or in aned, suspended or in any way way restricted by restricted by an institution, state ory an institution, state orlocality?locality?

Answer:Answer: Yes




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OOTHER INFORMATHER INFORMATIONTION

HaHavve ye you eou evver been coner been convicted of a Misdemeanor?victed of a Misdemeanor?

Answer:Answer: Yes


Background InformationBackground Information

• I graduated from a high school from which a low percentage of seniors receive a high school diploma.• I graduated from a high school at which many of the enrolled students are eligible for free or reduced price lunches.• I am from a family that receives public assistance (e.g. Aid to Families with Dependent Children, food stamps, Medicaid,

public housing) or I receive public assistance.• I am from a family that lives in an area that is designated as a Health Professional Shortage Area or a Medically

Underserved Area.• I participated in an academic enrichment program funded in whole or in part by the Health Careers Opportunity

Program.• I am a high-school drop-out who received AHS diploma or GED.• I am from a school district where 50% or less of graduates go to college or where college education is not encouraged.• I am the first generation in my family to attend college(neither my mother nor my father attended college).• English is not my primary language.

YYour parent's family income falls within the tableour parent's family income falls within the table's guidelines and y's guidelines and you are considered to haou are considered to havve met the criteria for economically disadvantaged:e met the criteria for economically disadvantaged:

Answer:Answer: Yes

What is yWhat is your geogrour geographic area?aphic area?

Answer:Answer: Large Town(population 10,000 to 49,999 population)

HaHavve ye you preou previously attended a medical school or health profession progrviously attended a medical school or health profession program, or matriculated/attended a medical school?am, or matriculated/attended a medical school?

Answer:Answer: Yes

ProgrProgram Tam Type:ype: Pharmacy (PharmD)

ProgrProgram Attended Description:am Attended Description: My summer training at TIFR has given me the experience of working in an organization oriented towardsresearch. In the course of the two months I spent there, my interaction with the Theoretical Compu

Attended FAttended From:rom: 01-20-2014

Attended TAttended To:o: 06-20-2016

Eligible to Return:Eligible to Return: Graduated

Reason for LReason for Leaeaving:ving: My summer training at TIFR has given me the experience of working in an organization oriented towardsresearch. In the course of the two months I spent there, my interaction with the Theoretical ComputerScience group has taught me a lot of things and also whets my appetite for more knowledge. I realize howimportant it is, as a researcher, to interact with other people working in the same field, and at the sametime, am able to work individually.My summer training at TIFR has given me the exper



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FFAMILAMILY INFORMAY INFORMATIONTION

MotherMother

Living:Living: No

First Name:First Name: Mary

Last Name:Last Name: Macintyre

Gender or SeGender or Sex:x: FEMALE

State/ProState/Province:vince: Texas

County:County: Bandera County

Country of Residence:Country of Residence: United States

Occupation:Occupation: Barber/Hairstylist

Highest Education LHighest Education Leevvel:el: Bachelor Degree (BA, BS, etc.)

Highest Education School Name:Highest Education School Name: BOSTON COLLEGE

Living in Primary Household:Living in Primary Household: Yes

PPeople in Primary Household:eople in Primary Household: 2



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AACADEMIC HISTCADEMIC HISTORYORY

HIGH SCHOOL AHIGH SCHOOL ATTENDEDTTENDED

Name:Name: JAMES WOODS HIGH

City:City: Springfield

State:State: Montana

GrGraduated:aduated: Yes

Date of GrDate of Graduation:aduation: 09-2013

COLLEGES ACOLLEGES ATTENDEDTTENDED

666384666384 DRADRAGON RISES COLLEGE OF ORIENTGON RISES COLLEGE OF ORIENTAL MEDICINEAL MEDICINE

Start Date:Start Date: 05-2008

End Date:End Date: 04-2016

State:State: Florida

Still Current:Still Current: No

Primary:Primary: Yes

Regionally Accredited:Regionally Accredited: N/A

Accredited By:Accredited By: N/A

MajorMajor 2nd Major/Minor2nd Major/Minor StatusStatus Degree VDegree Verifiederified Degree NameDegree Name Degree DateDegree Date

Industrial Pharmacy Entomology / Health Degree Awarded Yes Doctorate of Medicine 03-2016

COURSEWORKCOURSEWORK

666384666384 DRADRAGON RISES COLLEGE OF ORIENTGON RISES COLLEGE OF ORIENTAL MEDICINEAL MEDICINE

PrefixPrefix Course TitleCourse Title SubjectSubjectSpecialSpecialClassClass

Course TCourse Typeype CreditsCreditsVVerer..CreditsCredits

AppAppGrGradeade

CASCASGrGradeade

VVerer..GrGradeade

JuniorJunior SemesterSemester Summer 2Summer 2 2011:2011: CompletedCompleted aaVVerifiederified

Test Test Test Credit – NoSubject

NotApplicable

Not Applicable 3.0 C C

test test ChemicalEngineering

NotApplicable

89.33 A A

SeniorSenior SemesterSemester Summer 2Summer 2 2012:2012: CompletedCompleted aaVVerifiederified

Art Art Art NotApplicable

Not Applicable 4.0 A A



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SUPPORSUPPORTING INFORMATING INFORMATIONTION

EXPERIENCEEXPERIENCE

EXTRAEXTRACURRICULAR ACURRICULAR ACTIVITIESCTIVITIES TTOOTTAL HOURS: 444AL HOURS: 444

Experience TExperience Type:ype: Extracurricular Activities

Recognition TRecognition Type:ype: CompensatedVolunteer

Title:Title: Per Diem

EmploEmployyer:er: Extracurricular444kl North St33LittletonInternational 3333Uganda

Supervisor:Supervisor: MIcheal [email protected]

Experience Dates:Experience Dates: 01-01-2004/01-01-2017

Status:Status: Per-Diem

Hours per WHours per Week:eek: 222

TTotal Wotal Weeks:eeks: 2

TTotal Hours:otal Hours: 444

Experience Details:Experience Details: My summer training at TIFR has given methe experience of working in anorganization oriented towards research.In the course of the two months I spentthere, my interaction with the TheoreticalComputer Science group has taught me alot of things and also whets my appetitefor more knowledge. I realize howimportant it is, as a researcher, to interactwith other people working in the samefield, and at the same time, am able towork individually.My summer training atTIFR has given me the experience ofworking in an organization orientedtowards research. In the course of thetwo months I spe

PPermit to Contact:ermit to Contact: No



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SUPPORSUPPORTING INFORMATING INFORMATIONTION CONTINUEDCONTINUED


EMPLEMPLOOYMENTYMENT TTOOTTAL HOURS: 1390AL HOURS: 1390

Experience TExperience Type:ype: Employment

Recognition TRecognition Type:ype: Received Academic CreditVolunteer

Title:Title: Part time Job

EmploEmployyer:er: Healthcare333 Any St3333MargestonMaine 33339United States

Supervisor:Supervisor: Robert [email protected]


Status:Status: Part-time




Experience Details:Experience Details: 6My summer training at TIFR has givenme the experience of working in anorganization oriented towards research.In the course of the two months I spentthere, my interaction with the TheoreticalComputer Science group has taught me alot of things and also whets my appetitefor more knowledge. I realize howimportant it is, as a researcher, to interactwith other people working in the samefield, and at the same time, am able towork individually.My summer training atTIFR has given me the experience ofworking in an organization orientedtowards research. In the course of thetwo months I sp

PPermit to Contact:ermit to Contact: Yes

Experience TExperience Type:ype: Employment

Recognition TRecognition Type:ype: Received Academic Credit

Title:Title: Temp Job

EmploEmployyer:er: Employment113 West St999MarksonKansas 39939United States

Supervisor:Supervisor: Vince VincentVice [email protected]


Status:Status: Temporary





PPermit to Contact:ermit to Contact: No



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PHARMAPHARMACY EXPERIENCESCY EXPERIENCES TTOOTTAL HOURS: 400AL HOURS: 400

Experience TExperience Type:ype: Pharmacy Experience

Recognition TRecognition Type:ype: CompensatedReceived Academic CreditVolunteer

Title:Title: Full Time Job

EmploEmployyer:er: Pharmacy1232 Any St22323BostonMassachusetts 39039United States

Supervisor:Supervisor: Rod [email protected]

Experience Dates:Experience Dates: 01-01-2014/ Current

Status:Status: Full-time





PPermit to Contact:ermit to Contact: Yes

AACHIEVEMENTSCHIEVEMENTS

HONORSHONORS

Name:Name: Honors

Organization:Organization: Honors, Inc

Date:Date: 01-20-2016

Description:Description:

My summer training at TIFR has given me the experience of working inan organization oriented towards research. In the course of the twomonths I spent there, my interaction with the Theoretical ComputerScience group has taught me a lot of things and also whets my appetitefor more knowledge. I realize how important it is, as a researcher, tointeract with other people working in the same field, and at the sametime, am able to work individually.My summer training at TIFR hasgiven me the experience of working in an organization orientedtowards research. In the course of the two months I spent there, myinteraction with the Theoretical Computer Science group has taughtme a lot of things and also whets my appetite for more knowledge. Irealize how important it is, as a researcher, to interact with otherpeople working in the same field, and at the same time, am able to workindividually.



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AACHIEVEMENTSCHIEVEMENTS

PUBLICAPUBLICATIONSTIONS

Name:Name: Publication

Organization:Organization: Publications, Inc

Date:Date: 02-20-2014



SCHOLARSHIPSSCHOLARSHIPS

Name:Name: Scholarship

Organization:Organization: Scholarships, Inc

Date:Date: 05-22-1994



PERSONAL STPERSONAL STAATEMENTTEMENT

My summer training at TIFR has given me the experience of working in an organization oriented towards research. In the course of the two monthsI spent there, my interaction with the Theoretical Computer Science group has taught me a lot of things and also whets my appetite for moreknowledge. I realize how important it is, as a researcher, to interact with other people working in the same field, and at the same time, am able towork individually.My summer training at TIFR has given me the experience of working in an organization oriented towards research. In the courseof the two months I spent there, my interaction with the Theoretical Computer Science group has taught me a lot of things and also whets myappetite for more knowledge. I realize how important it is, as a researcher, to interact with other people working in the same field, and at the sametime, am able to work individually.My summer training at TIFR has given me the experience of working in an organization oriented towardsresearch. In the course of the two months I spent there, my interaction with the Theoretical Computer Science group has taught me a lot of thingsand also whets my appetite for more knowledge. I realize how important it is, as a researcher, to interact with other people working in the samefield, and at the same time, am able to work individually.My summer training at TIFR has given me the experience of working in an organizationoriented towards research. In the course of the two months I spent there, my interaction with the Theoretical Computer Science group has taughtme a lot of things and also whets my appetite for more knowledge. I realize how important it is, as a researcher, to interact with other peopleworking in the same field, and at the same time, am able to work individually.My summer training at TIFR has given me the experience of working inan organization oriented towards research. In the course of the two months I spent there, my interaction with the Theoretical Computer Sciencegroup has taught me a lot of things and also whets my appetite for more knowledge. I realize how important it is, as a researcher, to interact withother people working in the same field, and at the same time, am able to work individually.My summer training at TIFR has given me the experienceof working in an organization oriented towards research. In the course of the two months I spent there, my interaction with the TheoreticalComputer Science group has taught me a lot of things and also whets my appetite for more knowledge. I realize how important it is, as a researcher,to interact with other people working in the same field, and at the same time, am able to work individually.My summer training at TIFR has given methe experience of working in an organization oriented towards research. In the course of the two months I spent there, my interaction with theTheoretical Computer Science group has taught me a lot of things and also whets my appetite for more knowledge. I realize how important it is, as a



9 Generated: 2017-01-31 12:23PM


PERSONAL STPERSONAL STAATEMENTTEMENT

researcher, to interact with other people working in the same field, and at the same time, am able to work individually.My summer training at TIFRhas given me the experience of working in an organization oriented towards research. In the course of the two months I spent there, my interactionwith the Theoretical Computer Science group has taught me a lot of things and also whets my appetite for more knowledge. I realize how importantit is, as a researcher, to interact with other people working in the same field, and at the same time, am able to work individually.My summer trainingat TIFR has given me the experience of working in an organization oriented towards research. In the course of the two months I spent there, myinteraction with the Theoretical Computer Science group has taught me a lot of things and also whets my appetite for more knowledge. I realizehow important it is, as a researcher, to interact with other people working in the same field, and at the same time, am able to work individually.Mysummer training at TIFR has given me the experience of working in an organization oriented towards research. In the course of the two months Ispent there, my interaction with the Theoretical Computer Science group has taught me a lot of things and also whets my appetite for moreknowledge. I realize how important it is, as a researcher, to interact with other people working in the same field, and at the same time, am able towork ind

LICENSES AND CERLICENSES AND CERTIFICATIFICATIONSTIONS

Title:Title: License

License Number:License Number: 2

TType:ype: Licenses

Organization:Organization: Licenses, Inc

State:State: Delaware

Issue Date:Issue Date: 07-20-2004

Expiry Date:Expiry Date: 07-20-2020

Description:Description: My summer training at TIFR has given methe experience of working in anorganization oriented towards research.In the course of the two months I spentthere, my interaction with the TheoreticalComputer Science group has taught me alot of things and also whets my appetitefor more knowledge. I realize howimportant it is, as a researcher, to interactwith other people working in the samefield, and at the same time, am able towork individually.My summer training atTIFR has given me the experience ofworking in an organization orientedtowards research. In the course of thetwo months I spe

Title:Title: Certification

Certification Number:Certification Number: 34

TType:ype: Certifications

Organization:Organization: Certifications, Inc.

State:State: California

Issue Date:Issue Date: 04-04-2007

VValid Until:alid Until: 04-04-2017

Description:Description: My summer training at TIFR has given methe experience of working in anorganization oriented towards research.In the course of the two months I spentthere, my interaction with the TheoreticalComputer Science group has taught me alot of things and also whets my appetitefor more knowledge. I realize howimportant it is, as a researcher, to interactwith other people working in the samefield, and at the same time, am able towork individually.My summer training atTIFR has given me the experience ofworking in an organization orientedtowards research. In the course of thetwo months I spe



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CUSTCUSTOM QUESTIONSOM QUESTIONS

PHARMCAS RELEASEPHARMCAS RELEASE

** 1.1. I certifyI certify, as required in the application, that I ha, as required in the application, that I havve read and understand all application instructions, including the proe read and understand all application instructions, including the provisionsvisionswhich note that I am responsible for monitoring and ensuring the progress of mwhich note that I am responsible for monitoring and ensuring the progress of my application progress. I certify that I hay application progress. I certify that I havve reade readand will abide band will abide by all progry all program-specific instructions for mam-specific instructions for my designated Pharm.Dy designated Pharm.D. progr. programs. I certify that all the information andams. I certify that all the information andstatements I hastatements I havve proe provided in this application are current, correct, and complete to the best of mvided in this application are current, correct, and complete to the best of my knowledge. I understand thaty knowledge. I understand thatwithholding information requested on the PharmCAS application, or giving false information, mawithholding information requested on the PharmCAS application, or giving false information, may be grounds for denial ofy be grounds for denial ofadmission to a pharmacy institution participating in PharmCAS or maadmission to a pharmacy institution participating in PharmCAS or may be grounds for ey be grounds for expulsion from the institution I haxpulsion from the institution I havve beene beenadmitted and maadmitted and may prey prevvent me from entering the pharmacy profession. I givent me from entering the pharmacy profession. I give permission to PharmCAS to release ane permission to PharmCAS to release anyyinformation related to minformation related to my PharmCAS application to my PharmCAS application to my designated Pharm.Dy designated Pharm.D. progr. programs and other education associations. Iams and other education associations. Iacknowledge and agree that macknowledge and agree that my sole remedy in the ey sole remedy in the evvent of anent of any proy provved errors or omissions related to the handling ored errors or omissions related to the handling orprocessing of mprocessing of my application by application by PharmCAS is to obtain a refund of my PharmCAS is to obtain a refund of my PharmCAS application fee. I agree that my PharmCAS application fee. I agree that my admissiony admissionessaessays and other materials will be subject to submission for teys and other materials will be subject to submission for textual similarity rextual similarity review to iThenticate/Tview to iThenticate/Turnitin for Admissions forurnitin for Admissions forthe detection of plagiarism duplication as a potential violation of the PharmCAS applicant Code of Conduct. I am athe detection of plagiarism duplication as a potential violation of the PharmCAS applicant Code of Conduct. I am aware that allware that allsubmitted essasubmitted essays and other materials will be included as source documents in the iThenticate/Tys and other materials will be included as source documents in the iThenticate/Turnitin for Admissions referenceurnitin for Admissions referencedatabase solely for the purpose of detecting plagiarism of such documents. In connection with andatabase solely for the purpose of detecting plagiarism of such documents. In connection with any litigation between ory litigation between orincluding the parties hereto arising underincluding the parties hereto arising under, out of or relating to the application, I irre, out of or relating to the application, I irrevvocably consent to the eocably consent to the exxclusivclusive jurisdictione jurisdictionand vand venue in the United States District Court for the Eastern District of Virginia, Aleenue in the United States District Court for the Eastern District of Virginia, Alexandria Division; furthermore, I agree toxandria Division; furthermore, I agree topapay all of PharmCAS' reasonable and applicable attorney all of PharmCAS' reasonable and applicable attorneys' fees and costs in the eys' fees and costs in the evvent that I bring anent that I bring any dispute or litigation iny dispute or litigation inconnection with, regarding, relating to, arising out of or under the application and PharmCAS preconnection with, regarding, relating to, arising out of or under the application and PharmCAS prevails or the litigation isvails or the litigation isdismissed or withdrdismissed or withdraawn, with or without prejudice.wn, with or without prejudice.

Answer:Answer: Your certification of this statement serves the same purpose as a legal signature, and is binding.



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CUSTCUSTOM QUESTIONSOM QUESTIONS CONTINUEDCONTINUED

PHARMCAS CODE OF CONDUCTPHARMCAS CODE OF CONDUCT

** 1.1. PreamblePreamble

Once admitted to a professional pharmacy progrOnce admitted to a professional pharmacy program, students are considered to be members of the pharmacy profession andam, students are considered to be members of the pharmacy profession andtherefore bear the responsibility to adhere to the professional, ethical, and legal standards prescribed for the prtherefore bear the responsibility to adhere to the professional, ethical, and legal standards prescribed for the practice ofactice ofpharmacy and their college or school of pharmacypharmacy and their college or school of pharmacy. The ethical and legal responsibilities of student pharmacists are typically. The ethical and legal responsibilities of student pharmacists are typicallyrereviewed during orientation to the professional progrviewed during orientation to the professional program and throughout the time the student is enrolled in school.am and throughout the time the student is enrolled in school.Applicants to pharmacy progrApplicants to pharmacy programs, although not yams, although not yet members of the pharmacy profession, are liket members of the pharmacy profession, are likewise bound to legal andewise bound to legal andethical standards of behaethical standards of behavior during the admission process. Colleges and schools of pharmacy are encourvior during the admission process. Colleges and schools of pharmacy are encouraged to admitaged to admitapplicants with a high leapplicants with a high levvel of professionalism or professional potential.el of professionalism or professional potential.The Applicant Code of Conduct code proThe Applicant Code of Conduct code provides an evides an explicit statement of applicant responsibilities and explicit statement of applicant responsibilities and expected standards ofxpected standards ofperformance and behaperformance and behaviorvior. It is dr. It is draawn from the ethical principles of the Code of Ethics for Pharmacists as well as thewn from the ethical principles of the Code of Ethics for Pharmacists as well as theResponsible Conduct of Research values. Misconduct in anResponsible Conduct of Research values. Misconduct in any of the principles defined in the code will not be tolery of the principles defined in the code will not be tolerated. Anated. Anyyapplicant found to haapplicant found to havve violated the principles of conduct risks losing the privilege of applying to or entering the pharmacye violated the principles of conduct risks losing the privilege of applying to or entering the pharmacyprofession.profession.As an applicant to the profession of pharmacyAs an applicant to the profession of pharmacy, I pledge to:, I pledge to:

Act with honesty and integrity throughout the admission process when interAct with honesty and integrity throughout the admission process when interacting with school admissions officers, admissionacting with school admissions officers, admissioncommittees, and PharmCAS staffcommittees, and PharmCAS staff..Respect the knowledge, skills and values of those inRespect the knowledge, skills and values of those invvolvolved in the admission process, including the faculty and staff at schools ored in the admission process, including the faculty and staff at schools orcolleges of pharmacy and PharmCAS staffcolleges of pharmacy and PharmCAS staff..Respect the autonomRespect the autonomy and dignity of fellow applicants, admission staffy and dignity of fellow applicants, admission staff, college or school faculty, college or school faculty, staff, staff, and students, and an, and students, and anyyoneoneininvvolvolved in the admission process.ed in the admission process.Be responsible and accountable for mBe responsible and accountable for my actions and personally manage and respond to all matters related to my actions and personally manage and respond to all matters related to my application.y application.

PrinciplesPrinciples

The following section describes the principles that are the foundation of the Applicant Code of Conduct. The discussion thatThe following section describes the principles that are the foundation of the Applicant Code of Conduct. The discussion thataccompanies each principle is not intended to proaccompanies each principle is not intended to provide an evide an exhaustivxhaustive list of all possible situations or ee list of all possible situations or examples that maxamples that may bey beconsidered to be violations of the Code.considered to be violations of the Code.

As an applicant to the profession of pharmacyAs an applicant to the profession of pharmacy, I pledge to:, I pledge to:

Act with honesty and integrity throughout the admission process when interAct with honesty and integrity throughout the admission process when interacting with school admissions officers, admissionacting with school admissions officers, admissioncommittees, and PharmCAS staffcommittees, and PharmCAS staff. Integrity is an obligation that requires each applicant to pro. Integrity is an obligation that requires each applicant to provide information honestlyvide information honestly..Applicants must not falsify information (for eApplicants must not falsify information (for example, makxample, make a false claim to be an officer in an organization, falsify worke a false claim to be an officer in an organization, falsify workeexperience, plagiarize yxperience, plagiarize your personal essaour personal essay or proy or provide altered trvide altered transcripts). Applicants must also reanscripts). Applicants must also revveal information abouteal information aboutpreprevious legal offenses pertinent to admission to a professional progrvious legal offenses pertinent to admission to a professional program (for eam (for example, prexample, previous felonvious felony cony convictions or drug orvictions or drug oralcohol offenses). An applicant should accuralcohol offenses). An applicant should accurately represent herself or himself to staff and others during the admission process.ately represent herself or himself to staff and others during the admission process.It is inappropriate to contact admission staff to inquire about an application claiming to be someone else.It is inappropriate to contact admission staff to inquire about an application claiming to be someone else.Respect the knowledge, skills and values of those inRespect the knowledge, skills and values of those invvolvolved in the admission process, including the faculty and staff at schools ored in the admission process, including the faculty and staff at schools orcolleges of pharmacy and PharmCAS staffcolleges of pharmacy and PharmCAS staff. It is unacceptable for an applicant to dispar. It is unacceptable for an applicant to disparage the competence, knowledge,age the competence, knowledge,qualifications, or services of faculty and staff inqualifications, or services of faculty and staff invvolvolved in the admission process. It is inappropriate to imply in word, gesture, ored in the admission process. It is inappropriate to imply in word, gesture, ordeed that an application has been poorly managed or the applicant mistreated bdeed that an application has been poorly managed or the applicant mistreated by a staff member without tangible ey a staff member without tangible evidence.vidence.Professional relations among all members of the admission committees at schools of pharmacyProfessional relations among all members of the admission committees at schools of pharmacy, PharmCAS staff and applicants, PharmCAS staff and applicantsshould be markshould be marked with civilityed with civility. Thus, slanderous comments, uncivil language and abusiv. Thus, slanderous comments, uncivil language and abusive behae behavior should be avior should be avvoided, and eachoided, and eachperson should recognize and facilitate civil behaperson should recognize and facilitate civil behavior among all invior among all invvolvolved in the application process.ed in the application process.Respect the autonomRespect the autonomy and dignity of fellow applicants, admission staffy and dignity of fellow applicants, admission staff, college or school faculty, college or school faculty, staff, staff, and students, and an, and students, and anyyoneoneininvvolvolved in the admission process. The applicant should use the highest professional courtesy when intered in the admission process. The applicant should use the highest professional courtesy when interacting with fellowacting with fellowapplicants, admission staffapplicants, admission staff, college or school faculty, college or school faculty, staff, staff, and students, and an, and students, and anyyone inone invvolvolved in the admission process.ed in the admission process.OffensivOffensive or threatening comments via e-mail or ve or threatening comments via e-mail or voice mail messages or anoice mail messages or any other form of vy other form of verbal or nonerbal or nonvverbal communicationerbal communicationwill not be tolerwill not be tolerated. Inappropriate behaated. Inappropriate behavior includes the use of language, gestures, or remarks with sevior includes the use of language, gestures, or remarks with sexual oxual ovvertones.ertones.Applicants should maintain a neat and clean appearApplicants should maintain a neat and clean appearance, and dress in attire that is generance, and dress in attire that is generally accepted as professional bally accepted as professional by facultyy facultyand staff during their interview and when meeting with anand staff during their interview and when meeting with anyyone to discuss admission to a professional pharmacy progrone to discuss admission to a professional pharmacy program.am.Be responsible and accountable for mBe responsible and accountable for my actions and personally manage and respond to all matters related to my actions and personally manage and respond to all matters related to my application.y application.Applicants to a professional pharmacy degree progrApplicants to a professional pharmacy degree program must demonstram must demonstrate responsibility bate responsibility by taking ownership of all aspectsy taking ownership of all aspectsrelated to the application process. Applicants are erelated to the application process. Applicants are expected to rexpected to review application materials from PharmCAS and Pharm.Dview application materials from PharmCAS and Pharm.D..progrprograms to which theams to which they applyy apply. It is the applicant's responsibility to meet deadlines, pro. It is the applicant's responsibility to meet deadlines, provide information as requested, and followvide information as requested, and followthe admission process for each school or college to which thethe admission process for each school or college to which they applyy apply. Applicants, not PharmCAS, are responsible for promptly. Applicants, not PharmCAS, are responsible for promptly



12 Generated: 2017-01-31 12:23PM


PHARMCAS CODE OF CONDUCTPHARMCAS CODE OF CONDUCT

correcting ancorrecting any errors or omissions identified in the applicant's file. Applicants are ey errors or omissions identified in the applicant's file. Applicants are expected to respond to constructivxpected to respond to constructive feedbacke feedbackfrom admission staff and faculty bfrom admission staff and faculty by appropriate modification of their behay appropriate modification of their behaviorvior. If an applicant has a question about the. If an applicant has a question about thepharmacy admissions process after epharmacy admissions process after exhausting all axhausting all available online and printed resources, the applicant should contact thevailable online and printed resources, the applicant should contact theappropriate PharmCAS or pharmacy school admissions office directly for clarification. Staff will not discuss an application withappropriate PharmCAS or pharmacy school admissions office directly for clarification. Staff will not discuss an application withan applicant's parent, spouse, relativan applicant's parent, spouse, relative, friend, or emploe, friend, or employyer regardless of who submits the fee paer regardless of who submits the fee payment. The PharmCAS feeyment. The PharmCAS feepapayment does not relieyment does not relievve applicants of the obligation to properly submit all requested data and application materials be applicants of the obligation to properly submit all requested data and application materials by they thedeadline. Applicants who hadeadline. Applicants who havve not been accepted mae not been accepted may consult admission staff to learn how they consult admission staff to learn how they may may correct deficiencies iny correct deficiencies intheir application or academic performance or seek to learn more about admission criteria for schools to which thetheir application or academic performance or seek to learn more about admission criteria for schools to which they may may applyy apply,,but should remain respectful of decisions made bbut should remain respectful of decisions made by those iny those invvolvolved in the admission process.ed in the admission process.

Violation PViolation Policyolicy

Misconduct, as defined in the Applicant Code of Conduct, and all forms of dishonestyMisconduct, as defined in the Applicant Code of Conduct, and all forms of dishonesty, will not be toler, will not be tolerated in the applicationated in the applicationprocess. Pharm.Dprocess. Pharm.D. progr. programs from colleges and schools of pharmacy will determine whether an applicant has violated the Codeams from colleges and schools of pharmacy will determine whether an applicant has violated the Codeof Conduct and will report this to a Conduct Reof Conduct and will report this to a Conduct Review Committee, which is a sub-committee of the PharmCAS Advisoryview Committee, which is a sub-committee of the PharmCAS AdvisoryCommittee that will confirm if a violation has occurred and whether sanctions should be imposed. Sanctions imposed bCommittee that will confirm if a violation has occurred and whether sanctions should be imposed. Sanctions imposed by they thePharm.DPharm.D. progr. programs and the Conduct Reams and the Conduct Review Committee include, but are not limited to, review Committee include, but are not limited to, revvocation of application, or sharingocation of application, or sharinginformation with admission committees about the applicant's behainformation with admission committees about the applicant's behaviorvior. An. Any applicant found to hay applicant found to havve violated the principles ofe violated the principles ofconduct risks losing the privilege of applying to or entering the pharmacy profession. Conduct violations will be communicatedconduct risks losing the privilege of applying to or entering the pharmacy profession. Conduct violations will be communicatedto all schools and colleges of pharmacy in the Uto all schools and colleges of pharmacy in the U.S. as well as other health education associations..S. as well as other health education associations.If yIf you are found to haou are found to havve violated the Applicant Code of Conduct, AAe violated the Applicant Code of Conduct, AACP offers the option of one written appeal (via email). SuchCP offers the option of one written appeal (via email). Suchappeal must be requested in writing to AAappeal must be requested in writing to AACP within 10 business daCP within 10 business days of the notification to the applicant of the determinedys of the notification to the applicant of the determinedviolation and sanctions. The specific timing of the appeal process is determined bviolation and sanctions. The specific timing of the appeal process is determined by the timing of the applicant's submission ofy the timing of the applicant's submission ofmaterials for the Conduct Rematerials for the Conduct Review Committeeview Committee's consider's consideration. Specificallyation. Specifically, the applicant ma, the applicant may submit material separy submit material separately andately andafter submitting the notice of appeal. The members of the original Conduct Reafter submitting the notice of appeal. The members of the original Conduct Review Committee inview Committee invvolvolved in the determinationed in the determinationwill rewill review the request for appeal and anview the request for appeal and any new information proy new information provided. Anvided. Any rey revversal of the violation determination will beersal of the violation determination will becommunicated to all parties precommunicated to all parties previously notified.viously notified.In connection with anIn connection with any litigation between or including the parties hereto arising undery litigation between or including the parties hereto arising under, out of or relating to the application, y, out of or relating to the application, yououirreirrevvocably consent to the eocably consent to the exxclusivclusive jurisdiction and ve jurisdiction and venue in the United States District Court for the Eastern District ofenue in the United States District Court for the Eastern District ofVirginia, AleVirginia, Alexandria Division; furthermore, yxandria Division; furthermore, you agree to paou agree to pay all of PharmCAS' reasonable and applicable attorney all of PharmCAS' reasonable and applicable attorneys' fees andys' fees andcosts in the ecosts in the evvent that yent that you bring anou bring any dispute or litigation in connection with, regarding, relating to, arising out of or under they dispute or litigation in connection with, regarding, relating to, arising out of or under theapplication and PharmCAS preapplication and PharmCAS prevails or the litigation is dismissed or withdrvails or the litigation is dismissed or withdraawn, with or without prejudice.wn, with or without prejudice.

Answer:Answer: I certify that I have read and agree to abide by the Applicant Code of Conduct.

PREVIOUS STPREVIOUS STAATE OF RESIDENCYTE OF RESIDENCY

1.1. If yIf your durour duration of residency in yation of residency in your current state of residence is less than one your current state of residence is less than one yearear, list y, list your preour previous state of residence:vious state of residence:

Answer:Answer: West Virginia



13 Generated: 2017-01-31 12:23PM


SPECIAL LIFE CIRSPECIAL LIFE CIRCUMSTCUMSTANCESANCES

1.1. Please describe anPlease describe any special life circumstances. These include but are not limited to oy special life circumstances. These include but are not limited to ovvercoming advercoming adversity and culturersity and culturalalbackground.background.

Answer:Answer: My summer training at TIFR has given me the experience of working in an organization oriented towards research. Inthe course of the two months I spent there, my interaction with the Theoretical Computer Science group has taughtme a lot of things and also whets my appetite for more knowledge. I realize how important it is, as a researcher, tointeract with other people working in the same field, and at the same time, am able to work individually.My summertraining at TIFR has given me the experience of working in an organization oriented towards research. In the course ofthe two months I spent there, my interaction with the Theoretical Computer Science group has taught me a lot ofthings and also whets my appetite for more knowledge. I realize how important it is, as a researcher, to interact withother people working in the same field, and at the same time, am able to work individually.My summer training at TIFRhas given me the experience of working in an organization oriented towards research. In the course of the two monthsI spent there, my interaction with the Theoretical Computer Science group has taught me a lot of things and alsowhets my appetite for more knowledge. I realize how important it is, as a researcher, to interact with other peopleworking in the same field, and at the same time, am able to work individually.My summer training at TIFR has given methe experience of working in an organization oriented towards research. In the course of the two months I spentthere, my interaction with the Theoretical Computer Science group has taught me a lot of things and also whets myappetite for more knowledge. I realize how important it is, as a researcher, to interact with other people working in thesame field, and at the same time, am able to work individually.My summer training at TIFR has given me the experienceof working in an organization oriented towards research. In the course of the two months I spent there, my interactionwith the Theoretical C

FUTURE ENRFUTURE ENROLLMENT PLANSOLLMENT PLANS

** 1.1. Are yAre you currently enrolled, or planning to enroll, in anou currently enrolled, or planning to enroll, in any courses in Fall 2017?y courses in Fall 2017?

Answer:Answer: Yes

** 2.2. Are yAre you currently enrolled, or planning to enroll, in anou currently enrolled, or planning to enroll, in any courses in Spring 2018?y courses in Spring 2018?

Answer:Answer: No

AACADEMIC OR PRCADEMIC OR PROFESSIONAL INFRAOFESSIONAL INFRACTIONSCTIONS

** 1.1. WWere yere you eou evver the recipient of aner the recipient of any action (y action (e.g., a gre.g., a grade lowering penaltyade lowering penalty, failing gr, failing grade, disqualification, suspension, probation,ade, disqualification, suspension, probation,dismissal, etc.) bdismissal, etc.) by any any faculty membery faculty member, college, or univ, college, or universityersity, PharmCAS or health licensing board for academic or professional, PharmCAS or health licensing board for academic or professionalmisconduct (misconduct (e.g., cheating, plagiarism, hare.g., cheating, plagiarism, harassment, misuse of univassment, misuse of university facilities, stealing destroersity facilities, stealing destroying or damaging univying or damaging universityersityproperty etc.)?property etc.)?

Answer:Answer: Yes

2.2. If yIf you answered "ou answered "YYes" to the prees" to the previous question, enter an evious question, enter an explanation in the boxplanation in the box belowx below. Include 1) a brief description of the. Include 1) a brief description of theincident, 2) specific charge made, 3) consequence, and 4) a reflection on the incident and how the incident has impacted yincident, 2) specific charge made, 3) consequence, and 4) a reflection on the incident and how the incident has impacted yourourlife.life.

Answer:Answer: My summer training at TIFR has given me the experience of working in an organization oriented towards research. Inthe course of the two months I spent there, my interaction with the Theoretical Computer Science group has taughtme a lot of things and also whets my appetite for more knowledge. I realize how important it is, as a researcher, tointeract with other people working in the same field, and at the same time, am able to work individually.My summertraining at TIFR has given me the experience of working in an organization oriented towards research. In the course ofthe two months I spe



14 Generated: 2017-01-31 12:23PM

DESIGNADESIGNATIONSTIONS

PHARM DPHARM D

Organization:Organization: Watertown University

Department:Department: Pharmacy

ProgrProgram Lam Leevvel:el: PharmD

Enrollment:Enrollment: Fall 2015

Campus:Campus: —

DelivDelivery:ery: Classroom

Submitted Date:Submitted Date: 01-31-2017

Completed Date:Completed Date: 01-31-2017

VVerified Date:erified Date: 01-31-2017

Application Status:Application Status: Verified

Academic Update Status:Academic Update Status: —

Last Updated:Last Updated: 01-31-2017

SUPPLEMENTSUPPLEMENTAL QUESTIONSAL QUESTIONS

DOCUMENTSDOCUMENTS

Document RequestedDocument Requested UploadedUploaded File NameFile Name Uploaded DateUploaded Date

Image and Narrative 1 Yes SampleLOR.txt 01-31-2017

Image and Narrative 2 Yes SampleMedicalRecords.pdf 01-31-2017

Image and Narrative 3 Yes SampleOrders.docx 01-31-2017

Image and Narrative 4 Yes SampleCV.doc 01-31-2017

Image and Narrative 5 Yes DD-2058.pdf 01-31-2017



15 Generated: 2017-01-31 12:23PM

Dear Admissions Committee,

I had the pleasure of teaching Sara in her 11th grade honors English class at Mark Twain High School. From the first day of class, Sara impressed me with her ability to be articulate about difficult concepts and texts, her sensitivity to the nuances within literature, and her passion for reading, writing, and creative expression- both in and out of the classroom. Sara is a talented literary critic and poet, and she has my highest recommendation as a student and writer.

Sara is talented at considering the subleties within literature and the purpose behind authors' works. She produced an extraordinary year-long thesis paper on creative identity development, in which she compared works from three different time periods and synthesized cultural and historical perspectives to inform her analysis. When called upon to give her thesis defense in front of her peers, Sara spoke clearly and eloquently about her conclusions and responded to questions in a thoughtful way. Outside of the classroom, Sara is dedicated to her literary pursuits, especially to poetry. She publishes her poetry in our school's literary magazine, as well as in online magazines. She is an insightful, sensitive, and deeply self-aware individual driven to explore art, writing, and a deeper understanding of the human condition.

Throughout the year Sara was an active participant in our discussions, and she always supported her peers. Her caring nature and personality allow her to work well with others in a team setting, as she always respects others' opinions even when they differ from her own. When we held a class debate about gun laws, Sara opted to speak for the side opposite her own views. She explained her choice as motivated by a desire to put herself in other people's shoes, view the issues from a new perspective, and gain a clearer sense of the issue from all angles. Throughout the year, Sara demonstrated this openness to and empathy for the opinions, feelings, and perspectives of others, along with shrewd powers of observation, all qualities that makes her outstanding as a student of literature and burgeoning writer.

I am certain that Sara is going to continue to do great and creative things in her future. I highly recommend her for admission to your undergraduate program. She is talented, caring, intuitive, dedicated, and focused in her pursuits. Sara consistently seeks out constructive feedback so she can improve her writing skills, which is a rare and impressive quality in a high school student. Sara is truly a stand-out individual who will impress everyone she meets. Please feel free to contact me if you have any questions at [email protected].

Sincerely,

Ms. Scribe English TeacherMark Twain High School

Medical Record Documentation for Patient Safety and Physician Defensibility

A Handbook for Physicians

and Medical Office Staff

January 2008

Owned by the policyholders we protect.

Medical Record Documentation

for Patient Safety and Physician

Defensibility is a publication

of the MIEC Loss Prevention

Department. The authors

have conducted hundreds of

medical practice surveys and

have reviewed thousands of

medical records maintained

by physicians in all medical

specialties. Each of the authors

has extensive experience

in medical malpractice

claims management and

loss prevention activities

on behalf of physicians and

other health professionals.

Recommendations for

defensible medical records

are based on the authors’

analyses of medical records and

malpractice litigation files, and

include documentation advice

from malpractice defense

attorneys, claims experts and

physicians whose involvement

in peer review activities gives

them a unique understanding

of the importance of sound

medical record documentation.

No reproduction without

permission.

© Copyright 1998, 2003, 2008

Medical Insurance Exchange of

California, Oakland, CA.

Authors and Editors:

David Karp, B.A., M.A., Former Loss Prevention Manager, received a Bachelor of Arts degree from Columbia University and a Master of Arts degree from San Francisco State College. He was involved in medical malpractice claims and loss prevention activities on behalf of physicians between 1966 and 2000.

Judith M. Huerta, B.S., M.A., Loss Prevention Manager, received a Bachelor of Science degree from Chadron State College, Chadron, Nebraska and a Master of Arts degree from John F. Kennedy University, Orinda, California. She has been involved in medical malpractice claims and loss prevention activities on behalf of physicians since 1985.

Claudia A. Dobbs, B.A., M.A., Loss Prevention Assistant Manager, received a Bachelor of Arts degree and a Master of Arts degree from California State University at Hayward. She is a certified paralegal and was employed by a malpractice defense firm for ten years prior to joining MIEC’s Loss Prevention Department in 1992.

Dorothy L. Dukes, B.S., Senior Loss Prevention Representative, has extensive experience as a defense representative, claims reviewer, and paralegal for Dalkon Shield Claimants Trust and served as a family mediator for the Supreme Court in Richmond, Virginia. Ms. Dukes was a department supervisor for the American Arbitration Association in San Francisco, California, prior to joining MIEC’s Loss Prevention Department in 2001.

Kathy Kenady, B.A., Loss Prevention Representative, received a Bachelor of Arts degree from the University of California at Santa Cruz. She assisted in the Government Relations division of the California Medical Association in Sacramento, California, and went on to advocate for physicians and their patients for four years as the Associate Director of the Alameda-Contra Costa Medical Association in Oakland, California. She joined the Loss Prevention Department in March 2005.

This publication was developed and updated under the direction of the Loss Prevention Committee of the MIEC Board of Governors.

1

Table of Contents

Recommendations for Defensible Medical RecordsOrganize charts ....................................................................................................... 5Avoid the use of sticky notes ................................................................................ 5Note the reasons for visit ...................................................................................... 5Triage Template (Figure 1) .................................................................................... 5Chart allergies, current medications, names of other physicians ................... 6Consider a “Problem List” in group practice charts ......................................... 6Sign or initial all chart entries .............................................................................. 7Write legibly! ........................................................................................................... 7Dictated your records ............................................................................................. 8Consider an electronic medical record ................................................................ 8Avoid untimely dictation ........................................................................................ 8Do not use a “Dictated but not read” stamp or note on transcription ........... 9Initial or sign questionnaires as evidence of your review ................................ 9Fill in or void spaces on forms and transcription ............................................. 9Initial or sign lab, X-ray, consultants’ reports as evidence of your review ..... 9Lab, X-ray Report Review Template (Figure 4) ................................................ 10Avoid unexplained crossouts, writeovers or squeezed-in entries ................. 10Chart medication prescriptions and renewals completely .............................. 11Use a Medication Control Record ...................................................................... 11Medication Control Record sample (Figure 6) .................................................. 11Dispense drug education materials and document the details ...................... 12Document significant phone conversations with dates, names, and content ............................................................................................................ 13Document referral notes unambiguously .......................................................... 13Include sufficient details of exam findings in progress notes ......................... 13On-call Physician’s Report Form (Figure 7) ....................................................... 14Telephone Message Slip (Figure 8) ..................................................................... 15Supplement narrative text with line drawings, diagrams and templates ...... 15Document informed consent discussions carefully .......................................... 16Document “informed refusal” discussions ......................................................... 16Document patients’ noncompliance in the progress record .......................... 17Chart evidence that patient education information was dispensed .............. 17Document return visit advice in each progress note ....................................... 18Document failed and canceled appointments in the progress record ........... 18Did-not-keep-appointment (DNKA) Template (Figure 9) ................................. 18Resolve medical problems from previous visit in the chart .......................... 19Write unambiguous return-to-work or school orders....................................... 19Avoid unsubstantiated subjective remarks in the progress record ............... 19Avoid criticism of other professionals in chart notes ...................................... 19Use prenatal forms with adequate space for data; complete forms legibly .. 20Document prenatal risk evaluation ..................................................................... 20

Frequently Asked Questions about medical records ...................................... 21Documentation Review Self-Assessment ........................................................... 31

2

“ Nothing is more devastating to an innocent physician’s defense against the allegations of medical malpractice than an inaccurate, illegible or skimpy record, except for a record which has been changed after the fact, and therefore inevitably compromises the otherwise defensible case.”

Brad Cohn, MD, Pediatrician

Chairman, MIEC Board of Governors

Oakland, California

3

“ I have been involved with

the defense of physicians in

professional liability claims

since 1976. One common

thread that has existed in all

claims seen over the years is

that the medical record is the

physician’s greatest asset in

defending him or her against

allegations of negligence. If

more physicians realized that

clear, legible medical records

are their best defense and

they documented accordingly,

most claims would never be

brought, and many claims that

are contemplated would not

be pursued.”

Stephen D. Stimel

Former Claims Manager

Medical Insurance

Exchange of California

Medical Record Documentation for Patient Safety and Physician Defensibility

A Handbook for Physicians and Medical Office Staff

Few medical-legal topics have generated as much discussion as the subject of medical record documentation. Liability insurers, defense attorneys, and third-party payers remind physicians and other health professionals that the safety of patients, the outcome of litigation and the promptness of reimbursement depend on the adequacy, legibility, completeness, timeliness and accuracy of medical records.

Many malpractice claims result in a victory for the plaintiff because of the poor quality of medical records, even in cases in which appropriate medical care was provided. Maintaining adequate, defensible medical records need not be a chore. Ensuring that medical records are well-organized and reasonably complete may add a few minutes per chart to the physician’s day. But, physicians whose inadequate records were partly responsible for their involvement in litigation can attest to the fact that the amount of time spent in deposition, meeting with legal counsel, worrying about the case and its effect on their personal life and professional reputation, or preparing for and attending trial far exceeds the time it takes to maintain adequate medical records.

This handbook is a companion to MIEC’s sample forms, templates and letters — shortcuts to facilitate charting and maintain defensible medical records.

4

Weak medical records — an invitation to litigation

Medical records often are the most important objective evidence physicians and hospitals can offer in their defense against a malpractice claim. When jurors, arbitrators, pre-litigation screening panels or other triers of the facts must choose between conflicting, undocumented versions of events told by opposing parties, the documentation that was made at the time care was rendered is a defendant’s most decisive confirmation that he or she met accepted standards of medical practice. Weak medical records invariably handicap litigation defense. Liability experts are convinced that poor medical records are a leading reason so many questionable malpractice claims are filed and pursued, and why some of these cases ultimately are decided in the plaintiff’s favor. Poor medical records make it difficult to determine whether an adverse outcome resulted from factors beyond the physician’s control or from negligent medical care.

Aside from medical-legal considerations, the most important reason for physicians to maintain accurate, credible medical records is that good documentation protects patients. Medical records contain information required to inform physicians of past and present treatment decisions, and to provide evidence that such care was appropriate in all respects. Weaknesses in the charting increase the margin for error that could result in patient injury, or be an impediment to a physician’s defense.

Complete, timely records offer physicians a strong defense

Good documentation protects physicians and other health professionals against claims of negligence. Typically, when a patient asks an attorney to file a malpractice claim against a physician, hospital or other health professional, most attorneys obtain copies of the pertinent medical records for review by an independent medical consultant. The reviewer is asked to determine, based on the documentation, if the treating physician(s) provided appropriate care — and whether the physician was negligent.

Similarly, when a doctor reports a potential claim to MIEC’s Claims Department, the doctor’s defense attorney obtains and submits the medical records to independent medical reviewers, a medical society peer review committee and, where applicable, to a state-mandated pre-litigation screening panel. Each consultant or review panel is asked to consider the same question the plaintiffs’ consultants consider: Based on the documentation, did the physician provide appropriate medical care? The strength of the documentation often is the deciding factor in whether a plaintiff pursues a claim and in how effectively defendants and their insurers can mount a solid defense against the allegations.

5

Recommendations for Defensible Medical Records

Organize charts

Well-organized, neatly-maintained patient charts facilitate making new entries and locating previously-recorded information. Secure loose pages to the chart cover with two-pronged clips. In larger charts, use dividers to separate progress notes from lab reports, correspondence, copies of hospital reports, and other materials. Include the patient’s name or other identifier on each page in the medical record.

Avoid the use of sticky notes

Avoid the use of sticky notes or unattached slips of paper, which can become separated from the chart. MIEC’s office practice surveyors find that most notes written on loose slips of paper or Post-It® notes do not include the patient’s name, the full date of the note, other essential details or the writer’s initials. Sticky notes are meant to be temporary and lack space for the essentials of meaningful and permanent chart entries.

Note the reasons for visit

Begin each progress note with information about the reason for a patient’s office visit. The absence of this data handicaps the defense against allegations that the doctor failed to diagnose a problem the patient reported. As part of the intake or “triage” process, the doctor or an assistant should document the patient’s chief complaint using quotes, when applicable, to indicate the patient’s own words, and include the onset and duration of symptoms. Office staff should not translate the patient’s comments into a medical diagnosis or medical terminology. A sample complaint might read: “Pt. states: ‘Stomach pain, diarrhea, headaches for two days. Has taken aspirin three times.’” A rubber-stamp-template such as that in Figure 1 facilitates this documentation. Figure 1: Triage Template

Sample Triage Rubber Stamp Template

Date_______________ Weight _______BP _________/_________LNMP____________ Sitting Lying

Complaint(s) ____________________________________________________________________________________ (Onset/duration)

Allergies ___________________________________ Meds________________________ Patient’s other physicians: __________________________________________________ ___________________ Initials

Explanation: A nurse or medical assistant can use this template to easily document important information before the doctor sees the patient. The patient’s chief complaint or reason for the visit should include the onset and duration of symptoms. When indicated, the patient’s exact words should be used. Office staff who complete the template should never translate the patient’s comments into a medical diagnosis or medical terminology. Always note the name and relationship of the historian, if it is not the patient. Identify an interpreter by name and relationship.

6

Anyone who obtains this information should note clearly who the historian is, if it is not the patient. If the patient does not speak English or is hearing- impaired, include the name of the interpreter.

Chart allergies, current medications, names of other physicians

Ask patients on their first visit about drug or other allergies; periodically update this information. MIEC’s claims data reveals that the second most common category of medication-related claims involves the prescription of a contraindicated drug due to an unknown and/or overlooked allergy. To avoid overlooking patient allergies, physicians should document this significant information on a brightly-colored sticker placed on the cover of each patient’s chart or on a triage template (see Figure 2). When patients report “No-known-drug-allergies” (NKDA), document “NKDA” on the sticker or in the chart as evidence that the question was asked and allergies were denied.

Document the names of other treating physicians and note the conditions and/or medications they are managing. Ask patients about medications other doctors have prescribed since the previous visit, over-the-counter drugs, complementary and alternative supplements, and illicit drug use; document the information completely. Ask patients to bring all of their current medication vials to each appointment, so that the doctor can review them.

Consider a “Problem List” in group practice charts

When more than one physician in an office or clinic treats a patient and makes entries in a unified medical record, communication among the co-treaters can be facilitated by a problem list that identifies serious medical conditions and includes the dates of onset and resolution. The problem list entries alert co-treaters to review their colleagues’ progress notes and correlate their own treatment or follow-up advice. Caveat: Problem lists must be current and complete or they could mislead. You

Figure 2: Example of

completed Triage Template

Sample Triage Rubber Stamp Template

Date_______________ Weight _______BP _________/_________LNMP____________ Sitting Lying

Complaint(s) ____________________________________________________________________________________ (Onset/duration)

Allergies ___________________________________ Meds________________________ Patient’s other physicians: __________________________________________________ ___________________ Initials

Explanation: A nurse or medical assistant can use this template to easily document important information before the doctor sees the patient. The patient’s chief complaint or reason for the visit should include the onset and duration of symptoms. When indicated, the patient’s exact words should be used. Office staff who complete the template should never translate the patient’s comments into a medical diagnosis or medical terminology. Always note the name and relationship of the historian, if it is not the patient. Identify an interpreter by name and relationship.

7

Figure 3:“ Any lawyer who defends

medical malpractice cases can

regale you with stories about

claims and disasters that could

have been easily prevented

by more careful attention

to the patient’s chart. The

principal problem is usually the

absence of data, coupled with

a failure to note the treatment

recommendations conveyed to

the patient and/or the need for

follow-up appointments.”

Keith B. Brown, Esq.

Malpractice Defense

Attorney

Brown, Waller, & Gibbs

may wish to assign an assistant the responsibility to ensure that significant current visit information is added to the problem list.

Sign or initial all chart entries

Physicians and their staff should initial or sign their chart entries. Author identification gives chart entries credibility and limits the number of people a plaintiff’s attorney could question about an unattributed entry. Phone messages in which important information is received from or given to patients by the staff on the doctor’s behalf should be initialed (or signed) and dated. Medication refill notes should confirm that a physician approved the order (e.g., “per Dr. Jones”) and be initialed by the employee who relayed approval to a pharmacy. Staff notes should similarly indicate that medical advice relayed to patients came from the doctor.

In multi-specialty group practices, precede progress notes with the treating physician’s name and specialty or department. Medical assistants can imprint this data and the visit date with a rubber stamp.

Write legibly!

Everyone who writes in the medical record must ensure that entries are legible. Unreadable entries in a medical record usually are not a problem if only one physician relies on the chart — although poor handwriting has subjected many physicians to time-consuming depositions or court appearances just to decipher their writing. When more than one person has to read and interpret the records, including office staff or other physicians, the potential liabilities of poor handwriting increase dramatically. In both office and hospital charts, a carelessly written decimal point in a drug order, an unclear number on a laboratory report or vital signs note, or medical orders that even their author cannot decipher, are charting deficiencies that can result in expensive and difficult-to-defend lawsuits. Squeezed-in unreadable entries, initials or signatures that obscure medical notes,

8

improper corrections, writeovers, and crossouts are not only hazards in patient care, but weaken the credibility of documentation and the defense of a malpractice claim.

Dictated your records

Dictated and transcribed medical records are an alternative to illegible handwriting. Dictated progress notes tend to be more complete and thus more helpful in documenting patient care, and more supportive in the defense of a malpractice claim than are many handwritten charts. Their most important feature may be that the ease of dictation enables the physician to include extensive details of history, examination, educational and instructional discussions, and contacts with specialists and referring doctors. Writing fatigue and time constraints make some doctors handwrite less information than they are likely to include in a dictated note. Transcribed records are recommended in complex cases, and in cases in which more than one physician provides care. Dictated records are advisable in cases the doctor reasonably can expect will involve either litigation or liability claims, such as auto accidents, industrial injuries, and reportable abuse. In these cases, the treating physician may be called as a witness. The quality of his or her medical record could become the focus of the litigation or proceeding if medical information has not been accurately, legibly and consistently documented.

Consider an electronic medical record

An increasing number of software programs and complete documentation systems are available for physicians who want to computerize their medical records. When choosing an electronic medical record (EMR) system, physicians should first assess their practice management and documentation needs, and spend some time evaluating the EMR product and the company’s stability. Computerized medical records should include the essentials of good documentation as outlined in this text. Specifically, the EMR should offer (among other features): default fields that cannot be skipped (e.g., allergies, medications); reminders for health maintenance diagnostic testing; pop-up warnings about contraindicated medications due to allergies or prescribed drugs; safeguards against undetected alterations; an automatic backup system; and more. (See the EMR Supplement to this text.)

Avoid untimely dictation

Operative and procedure reports or discharge summaries dictated too long after an event may handicap physicians who care for hospitalized patients or who are on-call for another physician. Serious diagnostic and treatment errors have resulted in injury and litigation because these reports were not available. Reports dictated too long after a complication lack credibility, whether or not the complication resulted from negligence.

9

Do not use a “Dictated but not read” stamp or note on transcription

Some busy physicians believe this rubber stamped disclaimer excuses them from errors or omissions on reports or correspondence they sign. In fact, such attempts to limit liability actually increase it. If unreviewed reports contain errors or omissions that result in patient injury, in addition to claiming negligence, plaintiffs could allege in litigation that the doctor was “too busy” or “too unconcerned” to ensure the accuracy of an operative, History and Physical, or consultation report. Juries have not been sympathetic to the excuse that a doctor was too busy to protect patients by reviewing these important documents. It is difficult to correct errors or fill in blanks months or years after a report was dictated. It is even more difficult for doctors to convince jurors they meant to say something other than what appears on the report they dictated and sent without reading.

Initial or sign questionnaires as evidence of your review

Many medical practices ask patients to complete a questionnaire that documents information about past medical and surgical history, family medical history, and personal habits. These can be helpful forms as they provide the physician with useful information. As evidence that the physician has reviewed questionnaires and history forms, the doctor should initial the forms and, in the case of significant patient responses to questions, make a note next to these items (or refer to them in the progress notes) to indicate the patient’s responses were discussed and considered.

Fill in or void spaces on forms and transcription

A blank space on a form does not always signify a negative response. Plaintiffs’ attorneys and jurors may regard blank spaces on an examination template as evidence that parts of an exam were not done. On a questionnaire, patients may leave spaces blank because they did not understand or overlooked the question, are functionally illiterate, or did not know how to spell a medical or drug term. Fill in or void all spaces for information on forms. Ask office staff to review forms patients fill in to ensure the forms are complete. Physicians should not sign operative reports, discharge summaries, or other transcription before filling in blanks.

Initial or sign lab, X-ray, consultants’ reports as evidence of your review

A number of patient injuries and malpractice cases are traced to physicians’ failure to review and act upon positive laboratory and X-ray reports or treatment recommended in correspondence from consultants before these items are filed in the medical record. It is not fail-safe to file these reports in the chart with the expectation the doctor will review them the next time the

10

patient is seen; if the patient does not return, as some patients who became malpractice plaintiffs did not, the doctor may not discover significant findings that require action until the patient suffers an injury. Another unsafe but common practice is to assume that a report was reviewed because it is in the doctor’s “out” basket. Every liability insurer has had cases in which unreviewed reports somehow managed to get into the out basket and were filed, but were never reviewed by a physician. A safer approach is to require physicians to initial all reports as an indication to the staff that each item has been reviewed and can be filed; the staff would file such reports only if evidence of the physician’s review was clearly visible.

The template shown in Figure 4, which can be made into a rubber stamp, has space to note the physician’s review, and documentation that the patient was advised of the results.

Avoid unexplained crossouts, writeovers or squeezed-in entries

Crossouts or other unexplained changes or writeovers obscure both the original entry and correction. These changes often are cited by a plaintiff’s attorney to suggest that the medical record was intentionally altered. Correct writing errors by drawing a single line through the incorrect entry so that it can still be read. Write in the correction (legibly) and initial it. Avoid writing over any entry, especially digits (for vital signs, medication doses and amounts, etc.). Start a new

page, rather than squeeze in notes at the bottom or the sides of a full page. In litigation, such notes may appear to have been added with the intent to falsify the record after an adverse event occurred or after litigation was threatened.

Caveat: When amending progress notes, include the date, time and, if the reasons for the amendment are not obvious, explain the change. Never amend or correct a medical record after receipt of notice of a potential claim. Obtain advice from MIEC’s Claims Department if charting errors are discovered following a complication or after a claim is threatened or filed.

Caveat: Deliberate alteration of a medical record is illegal and unethical, and may subject the writer to criminal and civil penalties, including possible loss of the doctor’s medical license. The technology to detect documentation alterations is sophisticated and includes methods that accurately determine if entries on the page were made at the same or different times. Evidence of questionable late entries or alterations is usually admissible in court and strengthens the plaintiff’s case.

Figure 4: Lab, X-ray

Report Review Template

Lab/X-ray Report Review Template

Report reviewed by: ______________

Phone report to patient? Yes No

Phoned to: ______________________

Comments: ______________________ ________________________________ ________________________________

Date/Time: ______________________

By: ____________________________

Explanation: Physicians are encouraged to have a policy that staff members will not file important incoming reports or letters unless the doctor has initialed them. Physicians also can use a rubber-stamp template, such as the one above, to document both their review or reports and follow-up.

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Figure 5: Confusing

writeovers and crossouts

Chart medication prescriptions and renewals completely

As many malpractice claims involve medication problems, physicians should have a good system to ensure that they do not err in prescribing new drugs or granting renewals because they overlooked earlier prescriptions that were noted in the chart, but were not easily visible upon cursory review. Review of MIEC’s medication-related malpractice claims found that a large number of errors resulted when the prescribing physician overlooked earlier notations about prescriptions, particularly in offices in which more than one physician prescribed or renewed medications for the same patient. Some cases resulted when a physician prescribed a drug which was contraindicated because of an earlier prescription; the earlier prescription was appropriately documented, but the documentation was “buried” in the depths of the patient’s chart and apparently overlooked. In a number of cases involving allegations that too much medication was prescribed, the error was traced to the physician’s failure to notice that renewals were being ordered in increasingly shorter time spans. Again, the problem occurred because the medication information was buried in the body of the chart.

Use a Medication Control Record

The risks of harmful errors are reduced by maintaining a Medication Control Record (MCR) that lists all prescriptions and refills and is easily accessible for review. (Contact the Loss Prevention Department for a copy of an MCR or download one from the Loss Prevention section of MIEC’s website at www.miec.com.)

Physicians who choose to record medications in progress notes rather than on a medication control form should make certain that all entries are complete. Each entry should include the full name of the medication, dose, number dispensed and instructions. Medication renewal notes should be similarly complete. Notes that read, “Renew meds” are ambiguous — and may be misleading if the patient is

Figure 6: Sample MCR

Pharmacy:________________________________________________________ Phone:_____________________________________________

Start:____________________________________________ ___/___/___ ___/___/___ ___/___/___ ___/___/___ ___/___/___________________________________________________________________________________________ MD

Stop: ____________________________________________ Initials

No. of refills: _______ If sample, quantity: _________ StaffPatient handout: Initials: Initials

Start:____________________________________________ ___/___/___ ___/___/___ ___/___/___ ___/___/___ ___/___/___________________________________________________________________________________________ MD

Stop: ____________________________________________ Initials


Start:_____________________________________________ ___/___/___ ___/___/___ ___/___/___ ___/___/___ ___/___/_____________________________________________________________________________________________ MD

Stop: _____________________________________________ Initials


Start:_____________________________________________ ___/___/___ ___/___/___ ___/___/___ ___/___/___ ___/___/_____________________________________________________________________________________________ MD

Stop: _____________________________________________ Initials

No of refills: _______ If sample, quantity: _________ StaffPatient handout: Initials: Initials

Start:_____________________________________________ ___/___/___ ___/___/___ ___/___/___ ___/___/___ ___/___/_____________________________________________________________________________________________ MD

Stop: _____________________________________________ Initials


Start:_____________________________________________ ___/___/___ ___/___/___ ___/___/___ ___/___/___ ___/___/_____________________________________________________________________________________________ MD

Stop: _____________________________________________ Initials


Date

Refills

Date

Date

Date

Date

Date

Medications/Directions (Name, Dose, Amount, Instructions)

Medication Control Record

Patient Name:____________________________________________DOB:___/___ ___/ Phone:_______________________________________

Allergies:_____________________________________________________________________________________________________________

Meds Rx'd by other MDs:_______________________________________________________________________________________________

CompleteDate

BP 120/90Demerol 200 mg

40/70 150

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taking several medications and not all of them are due to be refilled at the same time the note was written.

Dispense drug education materials and document the details

Studies by the National Council on Patient Information and Education say that more than half of the prescriptions doctors order each year for patients of all ages are taken improperly or are not taken at all. According to the National Pharmaceutical Council, patients not taking medications as directed result in 125,000 deaths per year, 10% of all hospital admissions, 25% of all hospital admissions among the elderly, and 23% of all nursing home admissions.

These data underscore the importance of giving patients information about the drugs they are advised to take, and clear instructions for taking them. The studies also emphasize the need to take and periodically update an adequate medication use history, and to document the fact that information about drug side-effects was dispensed to the patient.

To increase patient understanding, promote patient compliance with medication instructions, and to reduce liability exposure, dispense written instructions for prescribed medications. Some commercial materials and some from medical specialty organizations are designed to familiarize patients with the drugs they are taking and to alert them to drug-related problems that they should call to the physician’s attention. Doctors who do not like pre-printed forms should consider writing their own drug information sheets.

When written materials are dispensed, a note should be made in the patient’s medical record. Medication information sheets may be numbered, so that documentation could consist of a note that says, for example: “PMI #007,” which means patient medication instruction sheet #007 was dispensed, and the patient was told to read it and let the doctor know if he or she had any questions. MIEC’s Medication Control Records have a space to indicate that printed information was dispensed.

Physicians who prefer to rely on oral advice should document in the progress notes that they have explained to patients each drug’s use, the directions for use, significant side effects and what to do if the patient experiences them, and other significant and/or educational information.

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Document significant phone conversations with dates, names, and content

Document in patient charts phone calls in which a physician receives or imparts important medical information. Documenting the calls in a separate log is risky, because: (1) co-treating physicians in the practice may not seek out and review logged messages about symptoms, medication changes or advice that might affect their own diagnostic or treatment decisions; and (2) as phone logs are not included when a pre-litigation copy of the patient’s chart is provided, the patient’s attorney may be unaware of telephoned information essential to understanding the case. Keep phone message pads at home and carry one on hospital rounds to facilitate documenting out-of-office phone calls. Many physicians dictate details of phone conversations into a small pocket recorder and have the notes transcribed when they return to the office or call their dictation service and record the details of a phone call. On-call physicians should document significant after-hours phone calls with their colleagues’ patients and remember to inform the colleague. The form shown in Figure 7 on page 14 can be used to document contacts with a colleague’s patients.

Office staff who receive phone calls from patients should document these calls in a consistent manner. An effective telephone message slip, similar to the example in Figure 8 on page 15, should have space for the physician or staff person to document actions taken (or directed by the doctor) in response to the patient’s call.

Document referral notes unambiguously

Document referral recommendations in unambiguous terms. Rather than note, for example, “to see GYN,” write, “Pt urged to see her GYN promptly for vaginal bleeding; patient understands urgency.” Instead of, “back pain—needs ortho,” write, “Pt says she will call today for an appt with orthopedist for back pain.” In place of “ENT for nasal polyp,” write, “Made appt for pt on 10/6/06 with Dr. Nohs for nasal polyp.”

Include sufficient details of exam findings in progress notes

In litigation, progress notes can be the strongest or weakest parts of the defendant’s medical record. Because of inadequate chart notes, hundreds of defendant-physicians have had only their recollections on which to base testimony about details of physical exams, postoperative bedside visits, advice they gave to patients, and medications they prescribed and renewed. In litigation, patient-plaintiffs often convincingly dispute their doctors’ undocumented recollections. Plaintiffs’ attorneys cite sparse progress notes to argue to jurors or arbitrators that office visits were too brief, or that examinations were perfunctory, just as the patient “remembers” and alleges. Phrases in progress notes like “OK;” “looks fine;” “normal neuro exam;” “headaches;” “ROS WNL (review of systems within normal limits);” or “some numbness,” are too ambiguous for defense experts to evaluate, and provide

14

Figure 7: On-Call

Physician’s Report Form

Date: ______________________ To: ________________________________________________________________, M.D. Re: Patient _____________________________________________________ This patient phoned on ________________________at ____________________o’clock. I saw this patient in Office Emergency Department ___________________________________at ____________________________ o’clock. Complaint/History (and historian)/Allergies/Medication: Examination: Impression: Action/Advice: Admitted to ________________________________________________ Patient advised to call you in _________days. Patient advised to go to ____________________Emergency Department Other: ______________________________________________________________ Medication prescribed: (Drug, dose, #, sig.) Phoned to ____________________________ Prescription written Attachment: ____________________________________________________________

On-Call Physician’s Report Form

Explanation: Physicians who are on-call for colleagues should document significant contacts with the colleague’s patients. Many physicians relay details of such contacts orally, but neglect to document the information. Print the form on 3-part carbonless paper and send the original to the patient’s primary physician. Retain a copy in an alphabetical or chronological file. Give the third copy to the patient as a reminder to follow the written follow-up instructions. Put office logo in the box at top of form.

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Figure 8: Sample

Telephone Message Slip

ammunition for the plaintiffs’ experts to question and criticize. These types of notes imply inattention or haste and have influenced the outcome of many “failure-to-diagnose” malpractice suits that physicians were forced to settle or which were lost at trial. More physicians are now dictating hospital progress notes in complex cases to ensure adequate documentation of their bedside evaluations and discussions with patients or their families. Haste is not an affirmative defense for inadequate documentation or resultant errors.

Patient-safe (and defensible) progress notes include sufficient information about: (1) reasons for the current visit; (2) the scope of examination; (3) positive and pertinent negative exam findings; (4) diagnosis or impression; (5) treatment details and future treatment recommendations; (6) medication administered, prescribed or renewed; (7) written (or oral) instructions and/or educational information to the patient; and (8) recommended return visit date.

Supplement narrative text with line drawings, diagrams and templates

These charting tools expand on narrative descriptions of the location of an injury or lesion, such as lacerations, burns, breast lumps, painful or erythematous areas, foreign body puncture sites, and neurological deficits. They add substance to indefinite phrases such as: “lump in upper outer quadrant left breast;” “laceration on plantar surface;” “facial acne;” “4 mm melanoma on back.” A simple line drawing supplements narrative descriptions of size, depth, scope or severity.

DATE: TIME: CALL TAKEN BY:_____________________________________ FOR: CALLER: ________________________________________________ PHONE: PATIENT NAME (IF NOT CALLER)___________________________ MEDICATION REQUEST: APPROVED BY: ______________

STAFF INITIALS: ______________

OTHER MESSAGE: DOCTOR'S RESPONSE: ACTION:

Sample Large Telephone Message Slip

Sample Small Telephone Message Slip

DATE: TIME: CALL TAKEN BY: _______________________________________ FOR: CALLER:__________________________________________________________________ PHONE: PATIENT NAME (IF NOT CALLER) ______________________________________________________ MEDICATION REQUEST: APPROVED BY: _______________________________________ OTHER MESSAGE: DOCTOR'S RESPONSE: ACTION:

FILE

16

“ For the plaintiff’s lawyer, a

case typically comes to his

office because of a perceived

bad outcome, but stays at his

office because of deficiencies

in the medical record. For the

defense, a medical malpractice

case most often begins and

ends with the medical record.

It is the singularly most

important testament to the

care which was and was not

provided, and often represents

the defendant physician’s

only ‘memory’ of that care. A

poorly documented record can

turn good medicine into an

indefensible case.”

Steven J. Hippler, Esq.

Malpractice Defense

Attorney

Givens Pursley, LLP

Document informed consent discussions carefully

Although a signed consent form technically is evidence of a patient’s consent to a surgery or invasive procedure, litigants often claim — and juries believe — they did not read or understand the lengthy form they signed, or that they signed it because they were told the procedure would be canceled if they did not. Even in states in which a signed consent form is prima facie evidence that a patient gave an informed consent, a consent form alone may lack credibility unless it is backed up by a physician’s handwritten or dictated note in the office or hospital record that verifies informed consent was obtained. Defense attorneys recommend that physicians document their informed consent discussions with a note similar to this: “The patient was advised of the purpose, benefits and significant risks of this procedure, including but not limited to bleeding, infection, (damage to adjacent structures or organs) (other specific, common risks). Alternative treatments and their risks, and the risks of non-treatment also were discussed. The patient’s questions were answered. (S)he appears to understand the risks of the procedure and gives his/her informed consent.” Defense attorneys further suggest that physicians indicate in the note who else (spouse, relative) was present during the informed consent discussion with the patient.

Important Note: Physicians should document informed consent discussions with patients in their office progress note, a History and Physical report, or a consultation report, but not in an operative or procedure report, which are dictated after the surgery or procedure. If problems occur, notes about pre-operative discussions of complications or potentially adverse outcomes in these after-the-fact reports appear self-serving and may lack credibility in court.

Physicians are encouraged to ask patients to sign a plain-language consent form for elective and non-emergency office surgery at the time the procedure is discussed. Include statements on the form for the patient to validate, such as: “Dr. (name) has explained to my satisfaction the purpose, benefits and alternatives to this procedure, the significant risks, and the consequences of not having the procedure. The doctor answered my questions and I wish to proceed.”

Document “informed refusal” discussions

Several states require physicians to inform patients who refuse medically essential surgery or diagnostic tests if there are potentially deleterious consequences to their decision. Informed refusal, if it is properly documented, protects physicians from liability for decisions the patient has made after being informed of the risks. A brief chart note such as: “Patient refuses test [or procedure]; explained risks of refusing treatment and degree of urgency, and patient understands,” generally suffices.

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Contact MIEC’s Loss Prevention Department for a Claims Alert with state-specific information on informed consent and informed refusal.

Document patients’ noncompliance in the progress record

Physicians should document a patient’s failure to follow advice, take medication, obtain requested diagnostic studies, keep an appointment with a consultant, or other actions the patient takes or fails to take that could cause or contribute to an injury or delay in resolution of a medical problem. Countless physicians have testified, without benefit of documented proof, that a patient’s claimed injury did not result from the physician’s negligence, but from the patient’s own action or inaction. In such cases, denials by patients or by survivors of deceased patients may appear believable when medical records do not support the defendant’s assertions of the patient’s carelessness. Sometimes documentation does exist, but it is too equivocal to resolve a dispute about what was said or done. Each of the following notes from actual cases helped somewhat in their writers’ defense, but would have been more convincing had the italicized text been included: “patient and husband refuse internal fetal monitor; limitation on our ability to identify fetal distress emphasized;” “patient refuses hospitalization and surgery; patient and wife informed of risks of surgery delay, including sudden death;” “patient continues to use alcohol and tobacco during pregnancy; again urged her to stop and stressed risks to fetus;” “patient has not kept cast dry as instructed; advised of possible delay in healing and risk of deformity; applied new cast; re‑instructed pt in mother’s presence;” “patient says he often forgets to take HTN meds; gave him written time/dose schedule for all drugs and discussed dangers of not taking all as ordered;” “patient refuses breast exam, says her GYN will do it next month; I stressed urgency of prompt evaluation of lump she said she felt.”

Chart evidence that patient education information was dispensed

Patients can sustain an injury when they misunderstand or cannot remember a physician’s oral advice. Patients who are not educated about the scope and limits of medical care and/or about their own responsibilities for self care, keeping appointments, or taking medication, often have unrealistic expectations of their physicians, and may sue when the outcome of treatment is not optimal. Increasingly, physicians are becoming convinced that second only to never making a mistake or never having a bad result, the most effective deterrent to patient injury and litigation is patient education. Written information on numbered handouts that supplements oral advice and instructions helps to inform patients of their condition, medication, or treatment; transfers responsibilities to patients; and reduces the physician’s liability.

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Figure 9:

Did-not-keep-appointment

(DNKA) Template

Documenting that written (or oral) medical information and advice were dispensed is essential. Some litigants claim they did not receive written material; others do not accurately recall the doctor’s oral advice or deny any was given. Documentation strengthens a physician’s defense against such claims. A note such as “PI #7” can be used to mean that the patient: (a) received Patient Information sheet #7; (b) was told to follow the written advice; and (c) was encouraged to ask questions about the material. Document oral advice with a note such as: “Discussed hypertension in detail. Pt understands med use and need for BP test every X weeks.”

Document return visit advice in each progress note

Conclude office visit progress notes by indicating when the patient was advised to return. Such notes help defend a physician in a malpractice case brought by a patient whose injury resulted from his or her own failure to return for follow-up. The documentation also prevents a patient whose failure to keep appointments resulted in injury from claiming the doctor was negligent for not suggesting a return visit. When no specific follow-up is required, a “return if any problems” or “return if (cite problems) occur” note means the doctor gave the patient the responsibility to decide when to return.

Document failed and canceled appointments in the progress record

Patients who consistently miss or frequently cancel appointments may place themselves at risk; some try to blame the doctor for injuries caused by their own negligence. Failed appointments documented in the patient’s chart are likely to be noticed by the attorney who obtains a pre-litigation copy of the medical chart to determine if a patient’s claim has merit. Few attorneys relish representing an injured patient who failed to heed a physician’s advice to return for further care. Failed or canceled appointments may be recorded in an appointment log or a computer scheduling program, but because the suing attorney does not have access to the log or scheduling system, he or she may not find out how

often the patient failed to keep appointments until the lawsuit is filed and the doctor’s deposition is taken — unless the information is in the chart. The template shown in Figure 9 can be made into a rubber stamp.

Did-not-keep-appointment (DNKA) Template

No Show Canceled ____________________

Initials

Rescheduled: by _____________________

Date Initials

Per Dr. :

Reschedule

No need to reschedule __________ __________ Initials Date

Patient Contacted:

By phone __________

By mail _________ _________ Initials Date

Explanation: When patients fail to return to their physicians as advised, they may contribute to their own injury. In litigation, some patients deny they were told to return. Doctors should document in the patient’s chart the return date they suggested. Appointment schedulers should document in the patient’s chart that patients missed, canceled or rescheduled an appointment. This template can be made into a rubber stamp for easy documentation of failed, canceled and rescheduled appointments.

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Resolve medical problems from previous visit in the chart

Medical problems reported on prior visits that were not resolved should be “red-flagged” to remind the writer of the need for follow-up on a subsequent visit. For example, a physician may document (i.e., red-flag) a decision to defer a diagnostic test pending results of a short course of medication. The next progress note should cancel the red-flag alert by indicating that: (a) the problem resolved; (b) further observation is planned; or (c) other actions (referral, tests, etc.) will be taken. If the physician neglects to cancel the red-flag with a closing note and the same or a similar problem surfaces in the future, it may be difficult to distinguish between a new complaint and the older, apparently untreated one. Ignored red-flag notes are serious defense problems in “failure-to-diagnose” claims.

Brightly-colored highlighter markers can be used to flag these important notes.

Write unambiguous return-to-work or school orders

To avoid injury to a patient, return to work advice should be specific and reflect an understanding of the patient’s job requirements. Orders for the patient to return to “light work” or “limited duty” may be misinterpreted by the patient or employer, or disregarded if the job duties cannot be modified as “light” or “limited.” The doctor’s orders should specify limitations on activities such as lifting, carrying, climbing, standing, or operating equipment. Return-to-school orders similarly should list specific activity restrictions.

Avoid unsubstantiated subjective remarks in the progress record

Medical record entries should be objective. For example, it is risky to refer to a patient as a “malingerer” or “alcoholic” or write that he “abuses drugs” without objective substantiation of these potentially harmful assertions. When a physical exam fails to explain a patient’s subjective complaints, it is best to say so, using professional language; e.g., “I am unable to find an objective explanation for the patient’s complaints of pain.” When making reference to alcohol, tobacco, or street drug use, include specific amounts reported by the patient. Terms such as “moderate,” “heavy,” or “occasional” are subject to broad interpretation. The physician should document objectively what the patient did or said that led the doctor to conclude the patient demonstrated “drug-seeking behavior.”

Avoid criticism of other professionals in chart notes

Comments critical of treatment by other health professionals are inappropriate in patients’ medical records. Too often, criticism is expressed by physicians who have not reviewed prior medical records or discussed the case with the previous physician, but instead relied on the patient’s

20

“Our legal system is oriented

to documents. Medical records

are central documents in the

defense of any malpractice

case. The medical record

usually is the most definitive

piece of evidence presented

at trial.”

Charles Bond, Esq.

Appellate and Medical

Law Attorney

Charles Bond & Associates

account of what occurred. Uninformed criticism of colleagues triggers a high number of unmeritorious law suits. Physicians should not use a patient’s office or hospital medical record to criticize nurses or to comment on the quality of services others provided or failed to provide. This is not to say that physicians or other healthcare professionals should suppress their legitimate concerns about patient care or about the responsiveness of others involved in the patient’s care. However, hospital and medical society peer review or quality assurance committees, not the medical record, are the appropriate forums for physicians and others to address issues related to a colleague’s competence, judgment or treatment choices.

Use prenatal forms with adequate space for data; complete forms legibly

Many prenatal forms provide minimal space for narrative notes about prenatal visits. OB-GYNs are advised to consider using a supplemental sheet for progress notes if their prenatal forms do not provide enough space to describe the patient’s complaints or lack of them, the results of physical examinations, and the substance of the doctor’s discussion and advice. A consistent finding in studies done of obstetrical injury malpractice cases was that the reviewers often were unable to piece together a patient’s prenatal course because of the scant progress notes, and therefore could not determine if the care was appropriate. The American College of Obstetricians and Gynecologists (ACOG) publishes the Antepartum Record, forms that assist physicians in their management of obstetrical patients and offer adequate space to document prenatal care. For information on ordering forms, contact: ACOG, 409 12th Street, SW, Washington, DC 20090-6920; 202/638-5577; website: www.acog.org.

Physicians should carefully review documentation in labor and delivery records prepared by hospital personnel. In these records, spaces for significant information should be filled in or voided, not left blank.

Document prenatal risk evaluation

The American Academy of Pediatrics (AAP) and ACOG’s Guidelines for Perinatal Care, as well as comments by expert obstetricians, indicate that physicians should adopt and document a formal risk evaluation system. ACOG’s Antepartum Record encourages obstetricians and their staffs to document risk factors, vital lab test results, ultrasound results, and more.

21

Frequently Asked Questions About Medical Records

The following are general answers to common questions about medical records. These answers are not intended as legal advice. Individual situations may require a more specific response. To the best of our knowledge, these answers are compatible with the Privacy Rules of the Health Insurance Portability and Accountability Act of 1996 (HIPAA). State laws prevail when contrary and more stringent than HIPAA. If an answer below conflicts with your interpretation of HIPAA as it applies to your practice, please consult your HIPAA resource. If your questions are more complex than those presented below and you would like to discuss the specific details, or if you have other general questions about medical records or their release, please contact MIEC’s Loss Prevention Department. For patient‑specific inquiries related to medical records or their release, call MIEC’s Claims Department.

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1. Are patients entitled to a copy of their medical records?

The physician (or the medical corporation if the practice is incorporated) owns the medical records generated by the practice. A physician is not obligated to relinquish original records, but must produce them for inspection and/or copying under certain circumstances.

Upon written request, a patient, former patient, parent or guardian of a minor patient, guardian or conservator of an incompetent patient, or legal representative of a deceased patient may be entitled to inspect and make copies of a patient’s medical records. However, some states allow physicians to withhold information if, in the physician’s medical judgment, release of the information could cause serious harm or be detrimental to a patient’s mental or emotional well-being. For information about your state’s laws concerning patients’ access to their medical records, please contact the Loss Prevention Department at 800/227-4527.

2. Can the doctor send a summary of the chart rather than a copy of the complete chart?

Each state has its own requirements if a physician elects to provide a summary of a patient’s chart rather than a complete copy of a record. Physicians are encouraged to call MIEC’s Claims Department if they are considering a written summary to comply with a request for a specific patient’s medical record. The Loss Prevention Department can provide general information for the content of a summary provided in lieu of a copy of the medical records.

3. Can we charge patients, lawyers, other physicians and insurance companies for copies of the medical chart? for copies of X-rays? How much can we charge?

Generally, yes, physicians can charge patients, lawyers, other physicians and insurance companies for copies of medical charts and X-rays. However, MIEC recommends that physicians use discretion and consider community practices when charging for medical information. For example, doctors usually do not charge a co-treating physician for copies of patient records, and many do not charge patients whose chart contains only a few pages. It also is not customary to ask the insurance company that is paying for the patient’s medical care to pay for a copy of the medical records. Physicians do generally pass on the cost of copying X-rays, and are entitled to charge for copies of medical records requested by an attorney or other physicians who are not involved in the patient’s care. The amount to charge per page varies from state to state. For information about HIPAA’s and your state’s laws concerning copying charges, please contact the Loss Prevention Department.

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Contact your county or state medical association for information about community practices.

Of note: Medical ethics and state and federal laws forbid physicians from withholding a copy of the medical record because a patient has an outstanding balance or cannot pay the copying fee. A patient’s continuity of medical care cannot be interrupted because of monies owed. See Question #10.

4. If our chart includes records received from another doctor, should we include the other doctor’s records when we respond to a subpoena that requests our chart? Should we include the other doctor’s records when we respond to a patient’s or attorney’s request for a copy of the chart?

Attorneys are divided on whether copies of another doctor’s records that are in your chart should be considered part of your chart, and therefore released in response to a subpoena or request for your records. Some states define “medical records” as information in the possession and control of the physician relating to any diagnosis, treatment, prognosis or history kept in connection with the treatment of a patient. Some attorneys advise that when asked to provide a copy of the patient’s medical record, a physician is required to include all of the information in a patient’s chart. Still others recommend that physicians provide only the information they have generated in their office; in such cases, the requesting party should be advised that the chart also contains partial or complete copies of medical records from other sources, and that these materials are not included in the copy. (Suggesting that requesters obtain copies of medical records from their original source is often a prudent approach, especially if you are not certain that the other doctor’s records are complete.) When you are uncertain about how to respond to a request for a copy of a specific patient’s medical records, contact the MIEC Claims Department for assistance.

5. Are law enforcement, state and federal agencies entitled to a copy of a patient’s chart upon request?

It depends on the circumstances of the request. In California, the California Medical Association warns physicians to consult with an attorney immediately upon receipt of a request for records from a law enforcement agency. In a criminal investigation, medical records may be obtained pursuant to a valid search warrant. State and federal authorities (e.g., the state medical board and Medicare) have a right of access to medical records in connection with an investigation by the entity.

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Physicians may be required to release medical records to law enforcement, state and federal agencies in connection with a reportable event such as child abuse, elder and dependent adult abuse, maternal substance abuse, sexual assault/rape, domestic violence and more. If you are unsure about whether to release a patient’s chart to a law enforcement agency, contact MIEC’s Claims Department for advice.

6. How long should we retain medical records? X-rays? Billing information?

Defense attorneys recommend that medical records, X-rays and billing information be retained “forever.” Because of possible exceptions to the statute of limitations (how long a patient has to bring a law suit), claims conceivably can be filed many years after the incident in question. The physician’s medical record is needed in every malpractice case. Patients may require a copy of their medical record for continuity of care, for answers to medical questions years after the conclusion of treatment, and for legal or medical needs in the future.

If “forever” is impractical in your practice, consider thinning records by removing the records of: (1) patients deceased for five years or more, when death was unrelated to treatment; and (2) patients not seen for at least eight years, when the care rendered was routine and/or short-term.

Other records should be kept for a longer period of time: records of (1) patients treated for serious or chronic illness particularly when treatment involved serious injury or complications; (2) patients treated for or during pregnancy; and (3) minors (until beyond their age of majority).

When a physician moves or retires and transfers custody of original records to another physician, the records should be maintained for a minimum of ten years by the custodial physician, who promises to make the records available to the patient upon appropriate request, and to the physician-owner of the chart. Additionally, the custodian of records promises not to destroy the charts without the physician-owner’s permission.

Hawaii: After eight years, physicians in Hawaii can destroy the medical records; however, they are required to retain “basic information” for 25 years after the last chart entry. “Basic information” includes the patient’s name and birth date, a list of dated diagnoses and intrusive treatments, and a record of all drugs prescribed or given. X-ray interpretations or separate reports must all be retained for 25 years. Medical records for minors must be retained for seven years after the minor’s eighteenth birthday; “basic information” must be retained 25 years after the minor’s eighteenth birthday.

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7. What type of information requires special authorization to release?

Many states have special confidentiality laws for the release of HIV test results, drug and alcohol abuse treatment, and in-patient mental health records. Federal laws also restrict the release of certain drug or alcohol treatment programs’ medical records. HIPAA privacy rules may be more permissive, but are superseded by contrary and more stringent state law. When in doubt, contact the MIEC Claims or Loss Prevention Departments, or your local medical society.

8. Can patients prohibit us from releasing parts of their charts in response to a subpoena or other request for the medical record?

If the subpoena or other request is accompanied by a general authorization, the physician must withhold information that is protected by special confidentiality laws (e.g. HIV test results, in-patient mental health records, and some drug and alcohol records). He/she should notify the requesting party that the chart contains state and federally protected data that cannot be released without a special authorization signed by the patient, and occasionally, by the treating physician.

However, when a patient requests that information not specifically protected be withheld from a requesting party, which is a patient’s right under HIPAA and many state laws, the physician should consider whether the omission is medically-significant and if its exclusion could mislead the recipient or result in injury. The physician should notify the recipient of the copy that information has been omitted at the request of the patient. The patient and the requesting party will then negotiate how to proceed.

For advice related to subpoenas, patients’ requests for records, or patients’ requests that information be omitted when records are released, call MIEC’s Claims Department.

9. Do we have to send the original chart in response to a subpoena duces tecum?

It depends on the state in which the physician practices. A subpoena duces tecum is the legal document used to compel production of medical records. Some states require that a physician or custodian of records make a personal appearance in court and bring the original chart. In other states, a physician can send a certified copy of the chart to the requesting party, accompanied by the custodian’s original declaration. We recommend that policyholders call MIEC’s Claims

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Department for state-specific advice and for answers to questions about how to respond to a subpoena duces tecum.

10. If a patient has not paid the doctor for services rendered, can we refuse to send a copy of the patient’s medical record to another physician? to an insurance company? to the patient?

No. There are no exceptions for withholding records until outstanding bills are paid. The American Medical Association’s Principles of Medical Ethics state “...medical reports should not be withheld because of an unpaid bill for medical services.” A patient may have a cause of action against a physician if the withholding of the medical records results in a harmful delay of treatment or the wrong medical care.

11. Can our original charts be turned over to the doctor who purchases the medical practice?

A physician who sells his/her practice may designate the purchaser as the custodian of records. The doctor may not, however, sell the records. Similarly, a physician cannot “transfer” patients to the purchasing physician’s practice. The seller may make recommendations to his/her patients that they continue their treatment with the new physician, but patients have the right to select any physician they choose.

It is prudent to specify in the purchase contract that the buyer will: (1) be custodian of the records; (2) maintain the records in a safe place; (3) make a copy available for transfer to any doctor to whom the patient requests such a transfer be made; and (4) make the records available to the selling physician in the event that they are needed in connection with litigation. The purchase agreement also should specify that the records will be held by the custodian for at least ten years, and that the records may not be destroyed prior to that time without the selling physician’s consent.

Some physicians, whether they sell their practice, simply retire or make a geographical move, make arrangements with a trusted colleague or partner to become the custodian of records upon the closing of a practice. A simple written agreement stating the previous four commitments and signed by the departing physician and the willing custodian of records should suffice to memorialize the understanding.

12. What should we do if a patient asks the doctor to delete information from his or her medical record, or asks the doctor not to document certain sensitive information?

We recommend that physicians never delete or omit any information

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they believe is pertinent to diagnosing and treating a patient. In some circumstances, improper deletion of medical information may even constitute unprofessional conduct by a physician.

Physicians should explain to patients the importance of documenting relevant information in the medical chart and how its omission may mislead others, including other physicians, who legally obtain a copy of the patient’s chart. Patients should be assured that all information in their medical chart is confidential and will not be released without the patient’s written authorization, except when the release is required by law.

HIPAA rules allow patients to request that their records be amended to correct incomplete or erroneous information by delivering a request to their physicians. (For HIPAA rules to apply, the physicians must be “covered entities” as defined by the federal regulations.) The requested amendment may be denied if: (1) the information was not created by the custodial physicians; (2) the information is not part of the health information maintained by the physicians; (3) the patient is not permitted to inspect or copy the information; or, (4) the information is accurate and complete. If the patient’s request for an amendment is denied, he/she must be informed of the reason for the denial and have the opportunity to submit a statement of disagreement to be kept in the chart, along with the original request.

13. Can we send copies of medical records by fax?

Yes, generally speaking, medical records can be sent by fax to the extent that their release has been appropriately authorized according to state law and/or HIPAA regulations. When physicians or hospitals send medical information by fax, they should take steps to ensure that the information is transmitted properly. To ensure confidentiality of faxed information:

A. Ask patients for authorization to send records by fax.

B. Establish policies governing emergency transmittals when patient authorization cannot be obtained.

C. Handle medical records transmitted by fax with the confidentiality required for any other medical records and medical information.

D. Place fax machines in areas where confidentiality is ensured.

E. Include a statement on the face sheet that: identifies the intended recipient; states that the content of the fax is confidential medical information; directs the recipient of a misdirected fax to call the sender and destroy the fax; and lists the sender’s name, fax number and telephone number.

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F. Confirm the fax number before transmittal.

G. Call to confirm the fax is received by the intended party.

H. Dial fax numbers carefully. If the fax number is misdialed and the information is transmitted, obtain the misdialed number from your fax machine’s internal log and refax a request to the unintended recipient asking that the transmitted information be destroyed.

I. Do not transmit prescriptions for controlled substances to patients or pharmacies by fax.

14. How can we thin out our medical records to reduce storage space? (See Question #6)

15. What should we do if, on review of a medical record, we discover significant errors in the charting or in dictated and transcribed reports?

Changes can be made to any medical records and it can be appropriate to correct errors, and sometimes to clarify a prior note. However, to ensure that such changes are not misinterpreted or viewed as efforts to falsify the record or to conceal or deceive, all changes or additions to a medical chart should: (a) be accurate and true; (b) include the date they are made; (c) include the writer’s initials or signature; and (d) when it is not clear why a change is being made, indicate what prompted the change or addition. When a new entry significantly changes information previously recorded, the old entry should not be removed. Rather than squeeze in a change, cross out the erroneous entry with a single line, being careful not to obscure what is written, and add an asterisk to call attention to the correction written in an available space on the dictated note or on a separate piece of paper.

If the error is the omission of information that should have been included in the entry, rather than squeeze such notes between original entries, write the addition in clear space and include the date, time and initials of the person adding the information. When appropriate, explain why an entry is out of sequence or context, or what prompted the addendum. Cross-reference the new entry to alert readers of its existence.

MIEC defense attorneys stress that physicians should consult legal counsel before making a significant change to a medical record. If the notes are written weeks or months after treatment or surgery, a jury in a malpractice case may have difficulty believing that defendants could recall so many details so long after an event. Do not alter a chart note after you learn that a patient intends to sue you; notes written after notice of potential litigation may decrease your credibility. “It is

29

easier to defend a case in which the documentation is not ideal, but adequate,” says a malpractice defense attorney, “than it is to explain to a jury what the doctor had in mind when he or she wrote a lengthy, apologetic addendum.”

16. Do we need the patient’s permission to permit other physicians who practice in our office to see the patient’s medical records?

No. The law (including HIPAA’s Privacy Act) generally permits physicians to share medical information for treatment and billing purposes with members of the same medical practice and other co-treaters. However, in a multi-specialty or large practice, physicians who are not involved in treating a patient of the practice should respect the confidentiality of each patient’s chart and follow the “need-to-know” rule, as should all employees.

17. What is the best way to destroy unneeded medical records?

Shredding or burning records are the safest ways to destroy medical records. Bonded commercial records destruction companies can be found in the Yellow Pages under “Business Records Destruction” or a similar heading. In some communities, hospitals may offer document-destruction services to members of the medical staff. Your local medical society may have the names of document destruction services.

18. Should we document in the patient’s chart incidents in which the patient was abusive to the physicians or staff?

Yes, but be objective in descriptions of the encounter. Chart entries should be specific. Physicians and their staff should objectively document what occurred, the patient’s demeanor during the encounter, and quote examples of the patient’s verbal attacks.

We also encourage physicians to establish a “zero tolerance” office policy for physically-violent or verbally-abusive patients. When a patient verbally assaults a staff member, a physician should be notified to come and speak with the patient. The doctor should decide whether such behavior warrants discharging the patient from the practice. Notify the local police immediately when a patient threatens or attempts to physically harm a physician or staff person. Call MIEC for advice about responding to specific non-emergent situations.

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19. Does the doctor have to enter his or her full signature after every progress note in the chart?

No. A physician is not required to enter his or her full signature after every progress note in the chart. (Some managed care credentialing agencies, and some hospitals, insist on a full signature for each progress note; others accept initials.) MIEC recommends that physicians, nurses, medical assistants, technicians, and other staff initial or sign every entry they make in the medical record, and that a signature/initial list of all employees (including physicians) be maintained by the practice manager. Notes are more credible when their author is identified.

20. What do we do if a medical record is lost?

Notify MIEC’s Claims Department or Loss Prevention Department for assistance. In some cases, a physician may be able to recreate the chart from memory, the billing records and from discussions with the patient.

21. Should we keep duplicates of hospital reports in the patient’s office chart?

Duplicates of some hospital reports may be helpful to the treating physicians and to colleagues in the same office who co-treat the patient. However, it is not necessary to retain copies of all hospital reports, since the original reports are available in the hospital record. If you rely on information contained in the hospital record to provide treatment in the office, it is prudent to retain the copies.

22. If we send a letter discharging a patient from the practice, should a copy be kept in the patient’s chart?

Yes. Remember to send discharge letters by certified mail. The green receipt, certifying that the patient received the withdrawal letter, should also be filed in the patient’s medical record. If the certified letter is returned to your office, file it in the patient’s chart and send a copy by regular mail.

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Documentation Review Self-Assessment

Instructions:Physicians are encouraged to periodically review a selection of their own medical records to assess and maintain the quality of their documentation. The Documentation Review Self‑Assessment form can be photocopied and used to document these reviews. Depending on the size of the practice and the quality of the medical record documentation, it may be appropriate to use a separate form for each provider in the practice. Or, one form may be used and the reviewer may enter pertinent notes about the habits of individual providers in the “comments” section. In some medical practices, an initial screening of the charts can be done by a qualified assistant; the assistant sets aside the charts that do not meet the listed criteria so that they can be reviewed by a physician. The results of the periodic reviews can be tracked over time and discussed at formal or informal meetings of the practice’s physicians.

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Documentation Review Self-Assessment

Number of charts reviewed: Date: By:

Criteria + - N/A Comments

Staff

Charts are well-organized

All chart entries are dated and signed or initialed

All handwriting is legible

There are no loose slips of paper or Post-it® notes

No unexplained crossouts, writeovers, squeezed-in notes

There are no blank spaces on chart forms, questionnaires, consent forms

Reasons for visit/complaints are noted

Other physicians the patient sees—and why—are noted

Current drugs patient is taking, including prescribed, complementary and alternative, OTC and “recreational” are noted

Allergies or “NKDA” are noted

Medication orders include the indications for use, drug name, dose, amount, directions, and number of refills authorized; renewals are clearly charted

Medication renewals include all of the above, plus who authorized the renewal and the initials of the person who “called in” the renewal

Evidence of dispensed written patient education materials is charted

Failed, canceled, rescheduled appointments are documented in chart

Significant phone calls are documented (content, advice, decisions, etc.), dated, signed

No unsubstantiated, subjective remarks are seen

Criteria + - N/A Comments

Providers (including nonphysician clinicians)

Handwriting is legible throughout

Dictation is timely, and bears evidence of physician review and correction

No “Dictated but not read” stamps seen

Patient questionnaires are initialed by providers as evidence of review

Significant phone calls (including those taken while on-call) are documented (content, advice, decisions, etc.), dated, signed

Progress notes adequately detail scope of exam, findings, history, treatment, recommendations, and include:

Medical history

SOAP (or similar) format

Pertinent positive and negative exam results

Impression or diagnosis; rule-out list

Treatment rendered in office and/or recommended for future visits

Why diagnostic tests were ordered or deferred; information reviewed by MD

Diagrams, when appropriate

Informed consent discussions

Informed refusal discussions

Documentation of noncompliance

Evidence of oral and written patient education dispensed

Unresolved medical problems are flagged, addressed and resolved

Follow-up advice given to patients

Patient-specific, unambiguous return-to-work/school orders, including limitations

Return visit date or timeframe for follow-up

Specific, unambiguous referral notes including indications, urgency, and patient understanding

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NMPS NORFOLK (UIC 3254A)

EMAIL ITINERARY TO [email protected] FOR AIRPORT PICKUP AND

BERTHING RESERVATIONS. ADDITIONAL INFORMATION ABOUT NMPS NORFOLK,

TO INCLUDE TRANSPORTATION AND BERTHING INFORMATION, IS LOCATED ON

THE NMPS WEBSITE HTTP://WWW.CNIC.NAVY.MIL/NMPS. CLICK ON THE NMPS

NORFOLK LINK. MEMBER IS TO CONTACT THE NMPS CDO AT 757-438-3375

WITH QUESTIONS OR IN CASE OF EMERGENCY. MEMBER WILL REPORT TO

NMPS WEARING THE UNIFORM OF THE DAY. IN THE EVENT OF ITINERARY

CHANGES MEMBER IS TO CONTACT THE NMPS CDO AND PROVIDE NEW ARRIVAL

FLIGHT NUMBER, AIRLINE, AND SCHEDULED ARRIVAL TIME.

STU DEF LANG INST WASHDC (UIC 47757):

- PRE-ARRIVAL TRAINING. PRIOR TO THE FIRST DAY OF TRAINING, GO TO

THE LEADER DEVELOPMENT AND EDUCATION FOR SUSTAINED PEACE (LDESP)

WEBSITE AT HTTP://WWW.LDESP.ORG. REGISTER FOR AN ACCOUNT; SELECT

THE CENTRAL ASIA TAB; AND COMPLETE THE TEN-HOUR CENTRAL ASIA

DISTANCE LEARNING BLOCK.

- UPON RECEIPT OF ORDERS, CONTACT NAVY'S CENTER FOR LANGUAGE,

REGIONAL EXPERTISE, AND CULTURE (CLREC) VIA E-MAIL AT

[email protected] OR PHONE AT 850-452-6736 (COMM) OR 922-6736 (DSN)

TO RECEIVE LANGUAGE AND CULTURE TRAINING PRODUCTS.

- UPON RECEIPT OF ORDERS, CONTACT AFPAK HANDS MANAGEMENT ELEMENT

(AME) FOR DLI INPROCESSING INSTRUCTIONS. LTC FRITZ GOTTSCHALK,

571-256-1510, [email protected]

MAJ GEOFF KENT, 571-256-1511, [email protected]

TSGT AARIN ROSE, 571-256-1512, [email protected]

IN MOST CASES, INPROCESSING WILL BE CONDUCTED AT DLI-W FACILITY,

201 12TH STREET SOUTH, SUITE 507, ARLINGTON, VA 22202, PH: 703-

604-0475. THE PACC POC WILL CONFIRM INPROCESSING PLANS FOR EACH

SPECIFIC CLASS.

-TO RECEIVE LANGUAGE AND CULTURE TRAINING PRODUCTS OR TO ARRANGE

FOR SUPPLEMENTAL TRAINING EVENTS, CONTACT NAVY'S CENTER FOR

LANGUAGE, REGIONAL EXPERTISE, AND CULTURE (CLREC) VIA E-MAIL AT

[email protected] OR VIA PHONE AT 850-452-6736 (COMM) OR 922-6736

(DSN)

ECRC DET CAMP ATTERBURY (UIC 46799):

FLY INTO INDIANAPOLIS INTERNATIONAL AIRPORT. SEND TRAVEL

ITINERARY TO THE EMAIL ADDRESS GIVEN BELOW. AIRPORT

TRANSPORTATION WILL BE ARRANGED BY CAMP ATTERBURY PERSONNEL.

REPORT TO BUILDING 509 UPON ARRIVAL AT CAMP ATTERBURY. GOV

QUARTERS AND MESSING MAY BE AVAILABLE. VISIT THE ECRC WEBPAGE AT

HTTP://WWW.ECRC.NAVY.MIL/, EMAIL [email protected]

FOR MORE INFORMATION. AFTER HOURS PHONE NUMBER 812-526-1339.

UPON COMPLETION OF TRAINING AT CAMP ATTERBURY, MEMBER IS AUTHORIZED

TO RETURN TO PARENT COMMAND OR TAKE LEAVE FROM CAMP ATTERBURY ON OR

ABOUT 20SEP12. FOR THOSE ELECTING TO TAKE LEAVE FROM CAMP

ATTERBURY, ANY TRAVEL EXPENSES INCURRED DURING LEAVE PERIOD WILL BE

THE MEMBER'S RESPONSIBILITY. REPORT BACK TO CAMP ATTERBURY ON OR

ABOUT 30SEP12.


ULTIMATE DUTY STATION (ULTDUSTA) INFORMATION:

MOB ACCOUNTING OPS KUWAIT (3954A):

COMUSNAVCENT EXERCISES OPERATIONAL CONTROL (OPCON) OF SAILORS

IN THE COMUSCENTCOM AREA OF RESPONSIBILITY (EXCLUDING SAILORS

ASSIGNED TO SPECIAL OPERATIONS). ONCE SAILOR IS BOOTS-ON-

GROUND (BOG) AND HAS COMPLETED IN-PROCESSING WITH COMMANDER

TASK FORCE-INDIVIDUAL AUGMENTEE (CTF-IA), NAVCENT FORWARD

HEADQUARTERS IRAQ, AFGHANISTAN, OR KUWAIT WILL DELEGATE

TACTICAL CONTROL (TACON) OF THE SAILOR TO THE SUPPORTED

COMMAND, BUT RETAIN ADMINISTRATIVE CONTROL (ADCON).

UPON ARRIVAL AT KUWAIT CITY INTERNATIONAL AIRPORT (KCIA)

NAVCENT FORWARD HEADQUARTERS KUWAIT PERSONNEL WILL FACILITATE

TRANSPORATION TO CAMP VIRGINIA. ONCE AT CAMP VIRGINIA NFHK

PERSONNEL WILL CONDUCT RECEPTION PROCESSING INCLUDING THEATER

ACCOUNTABILITY (CARD SWIPE), REQUIRED BRIEFINGS, ASSIGNMENT

OF BERTHING, COMMENCEMENT OF ENTITLEMENTS, AND TRANSPORTATION

ARRANGEMENTS TO ULTIMATE DUTY STATION.

- NAVCENT AUGCELL: DSN: 318-439-8915/9219/9896

EMAIL: [email protected]

HTTP://WWW.CUSNC.NAVY.MIL/CTF-IA/CTF-IA.HTM

- NAVCENT FWD HQ KUWAIT: DSN: 318-442-0183/2868,

CELL: 011-965-9720-3574 OR DUTY CELL: 011-965-9727-1840,

EMAIL: [email protected] OR

[email protected]

MOB ACCOUNTING OPS AFGHAN (UIC 3952A):

- MEMBER ADVISED: CONSERVATIVE/BUSINESS CASUAL ATTIRE IS REQUIRED

ON ALL OCONUS COMMERCIAL FLIGHTS. DUE TO THE INABILITY TO ACQUIRE

CIVILIAN CLOTHING IN AFGHANISTAN, MEMBER IS REQUIRED TO PACK ONE

SET OF CONSERVATIVE/BUSINESS CASUAL CLOTHING FOR USE IN THE EVENT

OF EMERGENCY LEAVE OR TDY TRAVEL.

AUGMENTEE WILL REPORT TO BAGRAM AIR BASE JOINT PERSONNEL RECEPTION

CENTER PRIOR TO MOVING TO FINAL DUTY STATION.

- NAVCENT AUGCELL: DSN 318-439-8968/3357/9896; EMAIL

[email protected]; HTTP://WWW.CUSNC.NAVY.MIL/CTF-IA/CTF-IA.HTM

- NAVCENT DET AFGHANISTAN: DSN 318-421-6662/6879, EMAIL

[email protected]

REFER TO MISSION/BILLET INFORMATION ABOVE. PERSONNEL IN GRADES

E7-E9, O3-O6, AND WO WITH ORDERS TO USFOR-A, USFOR-I,

CJTF-82, CSTC-A, OR CJTF-HOA MUST COMPLETE THE ONLINE JOINT

INDIVIDUAL AUGMENTEE TRAINING (JIAT) PROGRAM PRIOR TO DEPLOYING FOR

DUTY. GO TO HTTP://JKO.JFCOM.MIL/ [ON EITHER THE NIPRNET OR

INTERNET], SELECT THE "JOINT INDIVIDUAL AUGMENTEE TRAINING (JIAT)

PROGRAM" LINK NEAR THE BOTTOM OF THE PAGE, AND FOLLOW THE

INSTRUCTIONS TO ACCESS THE REQUIRED TRAINING. IF YOU HAVE

DIFFICULTIES OBTAINING AN AKO ACCOUNT CONTACT THE JKO HELP DESK AT

[email protected], COMMERCIAL (757) 203-5654 OR DSN (312)

668-5654. IF YOU HAVE DIFFICULTIES ACCESSING THE JIAT PROGRAM

WEBSITE OR HAVE QUESTIONS ABOUT THE PROGRAM CONTACT THE JIAT

PROGRAM COORDINATOR AT [email protected], COMMERCIAL (757)

203-5577, DSN (312) 668-5577.


PARENT COMMANDS OF INDIVIDUAL AUGMENTEES MUST ENSURE THE FOLLOWING

ADMINISTRATIVE ACTIONS ARE COMPLETED PRIOR TO DEPLOYMENT. IF

ASSIGNED A GLOBAL SUPPORT ASSIGNMENT (GSA) THROUGH YOUR DETAILER,

COMPLETION MUST BE ENSURED BY CURRENT COMMAND PRIOR TO DETACHING

AND PCS TO ECRC DET.

(1) UPON RECEIPT OF THESE ORDERS, YOU ARE DIRECTED TO CONTACT YOUR

DETAILER IMMEDIATELY IF YOUR ARE WITHIN 12 MONTHS OF YOUR PRD, OR

WILL ROLL INTO YOUR 9-MONTH NEGOTIATION WINDOW WHILE DEPLOYED TO

DISCUSS OPTIONS AVAILABLE. NOT APPLICABLE TO GLOBAL SUPPORT

ASSIGNMENTS (GSA).

(2) MEMBERS ARE DIRECTED TO SUBMIT THEIR FINAL TRAVEL CLAIM WITHIN

3 DAYS OF RETURNING TO PARENT COMMAND.

(3) FAMILY TRAVEL TO NMPS AND/OR ULTIMATE DUTY STATION IS NOT

AUTHORIZED.

(4) GOVERNMENT AIR AUTHORIZED FOR INCONUS TDY TRAVEL. GOVERNMENT

AIR IS DIRECTED WHERE AVAILABLE FOR OCONUS TDY TRAVEL.

(5) CIVILIAN ATTIRE MUST BE WORN ON CIVILIAN CARRIER DURING

TRAVEL.

(6) PER JFTR U1045 AND U4400, UTILIZATION OF GOVERNMENT QUARTERS

AND MESSING DIRECTED WHERE AVAILABLE. FOR GOVERNMENT LODGING

INFORMATION, VISIT WWW.DODLODGING.NET, FOLLOW LINKS FOR

APPROPRIATE U.S. INSTALLATION TYPE. FOR NAVY INSTALLATION LODGING,

CALL 877-NAVY BED (877-628-9233). RESERVATIONS ARE REQUIRED TO

ENSURE ROOM AVAILABILITY. CERTIFICATION IS REQUIRED FOR NON-

AVAILABILITY. APPROVING OFFICER OF INTERMEDIATE ACTIVITIES AND

GAINING COMMAND (ULTIMATE DUTY STATION) MAKES THE FINAL

DETERMINATION OF PER DIEM RATES (GMR, PMR, OR CMR) BASED ON THE

MESSING/BERTHING USE/AVAILABILITY PER JFTR U4400.

(7) EXCESS BAGGAGE AUTHORIZED. (UP TO 4 PIECES NTE 200 LBS.)

(8) MEMBERS REQUIRING NON-TEMPORARY STORAGE OF HHG AND/OR POV

PER JFTR U4770.B AND U5466 SHOULD CONTACT PERS4G3 BY SENDING

AN EMAIL REQUEST TO [email protected]. PLEASE REFERENCE YOUR

NE-####-#### LOCATED AT THE BOTTOM OF YOUR ITINERARY IN ALL

CORRESPONDENCE. FOR ELIGIBILITY OR ENTITLEMENT QUESTIONS,

PLEASE CONTACT THE HOUSEHOLD GOODS HELPLINE AT 800-444-7789.

REQUEST MUST BE RECEIVED A MINIMUM OF TEN BUSINESS DAYS PRIOR

TO EXECUTING THESE ORDERS.

(9) RESOURCES FOR ACQUIRING PT UNIFORMS IN THEATER ARE LIMITED.

SAILOR MUST BRING SUFFICIENT NAVY PT UNIFORMS. 3 TO 5 SETS

RECOMMENDED.

(10) ***THERE IS NO GUARANTEE OF EXTENSION***

TO EXTEND, MEMBER MUST HAVE NO LESS THAN 100 DAYS REMAINING ON

TOUR AND REQUEST EXTENSION VIA UNIT ASSIGNED. EXTENSIONS WILL

BE ROUTED FOR APPROVAL BY UNIT, THEATER HQ (I.E. NAVCENT FWD HQ),

PARENT COMMAND (ECRC FOR GSA), AND USFF. REQUESTS WILL NOT

NORMALLY BE GRANTED IF A REPLACEMENT HAS BEEN IDENTIFIED.

(11) FOR ALL OTHER QUESTIONS, CALL NPC CUSTOMER SERVICE CENTER AT

866-U-ASK-NPC.

MEMBER REQUIRED TO HOLD A TOP SECRET

SECURITY CLEARANCE FOR THIS ASSIGNMENT.

PARENT COMMAND MUST CERTIFY MEMBER'S SECURITY CLEARANCE BELOW:

(TO BE FILLED BY PARENT COMMAND)

IT IS CERTIFIED THAT SUBJECT MEMBER (SM) HOLDS A ________________

CLEARANCE ACCORDING TO DATA IN JPASS

SM CLEARANCE EXPIRES _________________________

THIS CLEARANCE STATEMENT COMPLETED BY ___________________________

COMMAND SECURITY MANAGER SIGNATURE ______________________________

COMMAND SECURITY MANAGER DSN PHONE NUMBER AND EMAIL

ADDRESS _________________________________________________________

PARENT COMMAND CO DSN PHONE NUMBER AND EMAIL

ADDRESS _________________________________________________________

(SIGNED)

D. P. QUINN

REAR ADMIRAL, U. S. NAVY

COMMANDER NAVY PERSONNEL COMMAND

//

BT

#0001

NNNN

`

Page 1 of CV for Darcy Austin

33 Pride Lane, Pembury, Derbyshire, DE11 8YR Eliza Bennett

Date of Birth: 15/05/1990 Nationality: British

Telephone Number: 01234 56789 Mobile Number: 07891 855555

Email Address: [email protected] Full Clean Current Driving Licence

My Objective

To enter a graduate training programme in multimedia, preferably in the new-media sector where mycreative initiative, ideas and a genuine enthusiasm would allow me to progress.

Academic

2005-July 2009: University of Kent Upper Second Class Honours (2:1) BSc Multimedia Technology and

Design with a Year in Industry.

Modules included:

q Introduction to Internet Technology – HTML, Java, XML

q Digital Photography

q Multimedia Applications

q Introduction to Programming – C#

q Virtual Worlds and 3D Modelling q Internet and Multimedia Platforms q Visual Effects and Compositing q Multimedia Studio II – Involved creating a 10-minute

documentary

Group project. The aim was to create a 5 minute 3D animated version of Pride and Prejudice.Production involved using all of the major aspects of Alias Maya, whilst also allowing me to extend myskills in other post-production software, such Adobe Premiere and After Effects. I achieved well aboveaverage marks for this project.

Technical Skills:q Alias Mayaq Macromedia Flash, Director and Dreamweaverq Adobe Photoshop, Premiere and After Effectsq Microsoft Office and Visual Studio

2003-2005: New College, Pembury ‘A’ Levels Computing A English Literature C History C

1998-2003: Wickham School, Derby 10 GCSEs grade C and above including English, Mathematics and Science

Creative

Ideas- Driven

Well-Organised

Persuasive

Strong TechnicalSkills

Self Starter

Enthusiastic

Teamworker

mailto:[email protected]

Page 2 of CV for Darcy Austin

33 Pride Lane, Pembury, Derbyshire, DE11 8YR Eliza Bennett

At work …..

July 2007 Persuasion Ltd, Winchester-Aug 2008: This was the placement year of my degree course where I was based in the

Web Design Department of Persuasion. Duties included developingapplications for clients as well as administrative tools for use within the department.This position called upon many skills I had learned as part of my degree andtested my ability to put them into practice in a ‘real world’ situation.

Aug 2006: Knightly International, Canterbury I was a temporary telesales person where it was my job to phone local

residents informing them of the benefits of becoming a member of aprestigious local hotel. I feel this position greatly enhanced mycommunication skills.

May 2004 PW World, Derby-Oct 2005: Part time Sales Assistant at a busy computing store.

Aug 2004: Mobil Oil Ltd, Croydon Work experience in the I.T. department in Croydon. Work involved

responding to staff’s technical problems and rewiring the network cabling ina newly refurbished section of the building.

What do I do in my spare time?

q I am a keen swimmer and have achieved bronze and silver ASA lifesaving awards.q I enjoy attending rock concerts and recently started to teach myself to play the guitar.

Referees

Dr A Smith Jean AustinLecturer in Multimedia Senior DesignerDepartment of Electronics Dept 4University of Kent Persuasion LtdCanterbury Cathedral TerraceKent WinchesterCT2 7DF Hampshire, PO4 4RR

Tel: 01227 824777 Tel: 02392 564839 email: [email protected] email: [email protected]

Creative

Ideas- Driven

Well-Organised

Persuasive

Strong TechnicalSkills

Self Starter

Enthusiastic

Teamworker

STATE OF LEGAL RESIDENCE CERTIFICATE

DATA REQUIRED BY THE PRIVACY ACT OF 1974

AUTHORITY:

PURPOSE:

ROUTINE USES:

MANDATORY ORVOLUNTARYDISCLOSURE:

Tax Reform Act of 1976, Public Law 94-455.

Information is required for determining the correct State of legal residence for purposes of withholdingState income taxes from military pay.

Information herein will be furnished State authorities and to Members of Congress.

Disclosure is voluntary. If not provided, State income taxes will be withheld based on the tax laws of theState previously certified as your legal residence, or in the absence of a prior certification, the tax laws ofthe applicable State based on your home of record.

NAME (Last, first, middle initial) SOCIAL SECURITY NUMBER (SSN)

LEGAL RESIDENCE/DOMICILE (City or county and State)

INSTRUCTIONS FOR CERTIFICATION OF STATE OF LEGAL RESIDENCE

The purpose of this certificate is to obtain information with respect to your legal residence/domicile for the purpose of determiningthe State for which income taxes are to be withheld from your "wages" as defined by Section 3401(a) of the Internal Revenue Codeof 1954. PLEASE READ INSTRUCTIONS CAREFULLY BEFORE SIGNING.

The terms "legal residence" and "domicile" are essentially interchangeable. In brief, they are used to denote that place where youhave your permanent home and to which, whenever you are absent, you have the intention of returning. The Soldiers’ and Sailors’Civil Relief Act protects your military pay from the income taxes of the State in which you reside by reason of military orders unlessthat is also your legal residence/domicile. The Act further provides that no change in your State of legal residence/domicile willoccur solely as a result of your being ordered to a new duty station.

You should not confuse the State which is your "home of record" with your State of legal residence/domicile. Your "home ofrecord" is used for fixing travel and transportation allowances. A "home of record" must be changed if it was erroneously orfraudulently recorded initially.

Enlisted members may change their "home of record" at the time they sign a new enlistment contract. Officers may not change their"home of record" except to correct an error, or after a break in service. The State which is your "home of record" may be your Stateof legal residence/domicile only if it meets certain criteria.

The formula for changing your State of legal residence/domicile is simply stated as follows: physical presence in the new State withthe simultaneous intent of making it your permanent home and abandonment of the old State of legal residence/domicile. In most cases, you must actually reside in the new State at the time you form the intent to make it your permanent home. Such intentmust be clearly indicated. Your intent to make the new State your permanent home may be indicated by certain actions such as: (1)registering to vote; (2) purchasing residential property or an unimproved residential lot; (3) titling and registering yourautomobile(s); (4) notifying the State of your previous legal residence/domicile of the change in your State of legalresidence/domicile; and (5) preparing a new last will and testament which indicates your new State of legal residence/domicile. Finally, you must comply with the applicable tax laws of the State which is your new legal residence/domicile.

Generally, unless these steps have been taken, it is doubtful that your State of legal residence/domicile has changed. Failure toresolve any doubts as to your State of legal residence/domicile may adversely impact on certain legal privileges which depend onlegal residence/domicile including among others, eligibility for resident tuition rates at State universities, eligibility to vote or be acandidate for public office, and eligibility for various welfare benefits. If you have any doubt with regard to your State of legalresidence/domicile, you are advised to see your Legal Assistance Officer (JAG Representative) for advice prior to completing thisform.

I certify that to the best of my knowledge and belief, I have met all the requirements for legal residence/domicile in the State claimedabove and that the information provided is correct.

I understand that the tax authorities of my former State of legal residence/domicile will be notified of this certificate.

SIGNATURE DATECURRENT MAILING ADDRESS (Include ZIP Code)

DD Form 2058, FEB 77 (EG) Designed using Perform Pro, WHS/DIOR, Jul 94

PRESUBMISSION RELEASEPRESUBMISSION RELEASE

By answering Yes, you authorize PharmCAS to release your name and contact information to your designated programs BEFORE you submityour final application. This will allow your designated programs to send you important information about the local admissions process beforeyou complete your application.

Presubmission Release Answer:Presubmission Release Answer: Yes



16 Generated: 2017-01-31 12:23PM

EVEVALUALUAATIONSTIONS

EVEVALUALUAATTOR INFORMAOR INFORMATIONTION

MichaelMichael J FJ Fooxx

Title:Title: Evaluator

Occupation:Occupation: Reference

Organization:Organization: Evaluations, Inc.

Email:Email: [email protected]

DaDaytime Phone:ytime Phone: 6175551212

Date Completed:Date Completed: 01/31/2017

Status:Status: Completed

I waivI waive me my right of access to this ey right of access to this evaluation:valuation: YES

How long haHow long havve ye you known the applicant?ou known the applicant? 2-3 years

How well do yHow well do you know the applicant?ou know the applicant? Minimally

In what capacity do yIn what capacity do you know theou know theapplicant?applicant?

Advisor

If yIf you selected "Instructor/Professor"ou selected "Instructor/Professor"aboabovve list all courses in which ye list all courses in which you haou havve hade hadthe applicant (for ethe applicant (for example: Intro toxample: Intro toChemistryChemistry, Chem 101), Chem 101)

Chem 201

If yIf you selected "Emploou selected "Employyee/ee/Supervisor" or "Colleague/Supervisor" or "Colleague/CoworkCoworker" aboer" abovve, please indicate thee, please indicate theapplicant's position and title:applicant's position and title:

Employee

REFERENCE RAREFERENCE RATINGSTINGS

ExExcellentcellent GoodGood AAvvererageage Below ABelow Avvererageage PPooroor N/AN/A

AdaptabilityAdaptability a

EmpathEmpathyy a

EthicsEthics a

Intellectual AbilityIntellectual Ability a

Interpersonal RelationsInterpersonal Relations a

JudgmentJudgment a

LLeadershipeadership a

OrOral Communicational Communication a

Professional AppearProfessional Appearanceance a

ReliabilityReliability a

Written CommunicationWritten Communication a

RECOMMENDRECOMMENDAATION CONCERNING ADMISSIONTION CONCERNING ADMISSION

I recommend this applicant with some reservationsI recommend this applicant with some reservations



17 Generated: 2017-01-31 12:23PM

EVEVALUALUAATIONSTIONS CONTINUEDCONTINUED


VivicaVivica FFooxxxx



Organization:Organization: Evaluations, Inc





I waivI waive me my right of access to this ey right of access to this evaluation:valuation: NO




Internship/Job Shadowing


Psych 101


CoWorker




EmpathEmpathyy a

EthicsEthics a



JudgmentJudgment a







I recommend this applicant with some reservationsI recommend this applicant with some reservations



18 Generated: 2017-01-31 12:23PM

EVEVALUALUAATIONSTIONS CONTINUEDCONTINUED


JamieJamie FFooxxxx



Organization:Organization: Evaluations, Inc





I waivI waive me my right of access to this ey right of access to this evaluation:valuation: YES




Employee/Supervisor


Libr 112


Colleague




EmpathEmpathyy a

EthicsEthics a



JudgmentJudgment a







I highly recommend this applicantI highly recommend this applicant



19 Generated: 2017-01-31 12:23PM

Documents

PharmCAS 2017-2018 Cycle Macintyre, megrady444 … PharmCAS...PharmCAS 2017-2018 Cycle Macintyre, megrady444 Applicant ID8949477491 Application StatusVerified Watertown University